Management of Fractures

1. Initial Assessment and First Aid

• History: Mechanism of injury, time elapsed, comorbidities, medications
• Radiographs: Always obtain AP, lateral, and oblique (45° rotation toward and away from film) views before any manipulation. Incomplete radiographic assessment leads to incomplete diagnosis. (Pye's Surgical Handicraft, 22nd ed., p. 167)
• Neurovascular assessment: All fractures must have distal circulation assessed and documented at presentation. If blood supply is affected, the fracture or dislocation must be rapidly reduced - this commonly restores circulation. (Mulholland & Greenfield's, p. 1407)
• Splintage: Early splintage reduces pain, blood loss, and soft tissue injury

2. General Aims of Fracture Treatment (The 4 Rs)

3. Methods of Fracture Reduction

A. Closed Reduction

• Performed under adequate analgesia or anesthesia
• Traction applied along the axis of the limb, followed by reversal of the deforming force
• Confirmed by post-reduction radiographs
• Suitable for most displaced closed fractures

B. Open Reduction

• Indicated when closed reduction fails or is inadequate
• Required for articular fractures needing anatomical reduction
• Needed when soft tissue or neurovascular structures are interposed

4. Methods of Fracture Retention (Immobilization)

A. Conservative (Non-Operative) Methods

• Immobilizes joints above and below the fracture
• Used for stable, minimally displaced fractures
• Requires monitoring for swelling (compartment syndrome risk)

• Skin traction: for temporary immobilization in children and elderly
• Skeletal traction: via Steinmann pin or Kirschner wire through bone
• Used for femoral shaft fractures, acetabular fractures, pelvic injuries
• For central hip dislocations, a Steinmann pin through the greater trochanter with lateral traction can overcome central redislocation tendency (Pye's Surgical Handicraft, p. 167)

• Applied once acute swelling resolves
• Used for humeral shaft and tibial shaft fractures
• Patient instructed on twice-daily brace tensioning; active joint motion applies hydrostatic and compressive forces at the fracture site
• Weekly skin checks and radiographs for 3 consecutive weeks
• If gross motion present at 6 weeks, consider surgical fixation (82% sensitive, 99% specific for predicting nonunion) (Rockwood & Green's, p. 1513)

• For upper limb fractures with minimal displacement

B. Operative Methods

• Uses percutaneous pins connected to an external frame
• Indications: open fractures with soft tissue compromise, polytrauma, temporary stabilization ("damage control orthopaedics"), infected fractures, periarticular fractures
• Reduces risk of further contamination in open fractures

• Requires clear understanding of fracture geometry and deforming forces
• Careful soft tissue management and judicious debridement are essential
• Despite direct visualization, plate fixation demands surgical experience

• Closed reduction and spica cast immobilization
• Skeletal traction
• Femoral cast bracing
• External fixation
• Intramedullary nailing (open or closed technique) - preferred
• Internal fixation with plate

5. Management of Open Fractures

Gustilo-Anderson Classification

Management Steps

1. Immediate general measures:
   • Tetanus prophylaxis
   • Early broad-spectrum IV antibiotics
   • Early splintage
   • Wound dressing (saline-soaked, not dry)
2. Early surgical management (Table 28.4):
   • Debridement to healthy margins + profuse wound lavage/decontamination: The most difficult step; must not be delegated to inexperienced staff; the whole zone of injury must be assessed; all dead and dying tissue removed (only nerve and vessel preserved); poor muscle specifically excised
   • A single adequate debridement is essential - repeated debridements "to make sure" indicate inadequate initial surgery and massively increase infection rate
   • Free bone fragments or fragments attached by flimsy soft tissue should be removed
   • Bony stabilization: Essential early; reduces late infection and facilitates soft tissue reconstruction
   • Early healthy soft tissue cover: Best evidence supports immediate flap cover after adequate debridement in complex Grade IIIb injuries
3. Definitive care sequence (achievable standard):
   • Primary procedure: debridement + fracture stabilization + soft tissue assessment
   • Second OR visit (~48 hours): definitive soft tissue cover
   • Plastic surgical team involvement from the start is essential

6. Special Situations

Vascular Injury with Fracture (Mulholland & Greenfield's, p. 1407)

• Acutely ischemic limb is a major surgical emergency
• Rapid fracture/dislocation reduction (often restores circulation)
• If not resolved: emergent combined vascular-orthopaedic procedure
• Temporary shunt for distal flow while bony reconstruction performed
• Bony stability must be obtained at correct length BEFORE definitive vascular repair - to ensure repair is at correct level/tension and is protected from disruption
• Fasciotomy mandatory to prevent reperfusion compartment syndrome

Compartment Syndrome (Mulholland & Greenfield's, p. 1407)

• Surgical emergency: muscle is acutely ischemic
• Classic presentation: pain out of proportion to injury
• Diagnosis: compartment pressure measurement; if pressure remains within 30 mmHg of diastolic BP (Delta-P <30 mmHg), fasciotomy is indicated (McQueen's criterion)
• Presence of distal pulse does NOT exclude compartment syndrome
• Treatment: immediate fasciotomy
• Particularly important to monitor in: patients under anesthesia (especially regional), sedated ICU patients, and those on strong analgesia

Fracture-Dislocation (Pye's Surgical Handicraft, p. 166-167)

• Requires complete radiographic assessment (AP, lateral, oblique views) before manipulation
• Attempt manipulation under anesthesia: axial traction to restore head to normal position
• If reduction inadequate or incomplete: open reduction should be considered
• Alternative (when expertise unavailable): accept position and maintain traction for 12 weeks
• Even severe residual acetabular displacement with stable head can give surprisingly good function

7. Rehabilitation

• Begin as early as possible within the constraints of fracture stability
• Aims: restore joint motion, muscle strength, and full functional independence
• Passive ROM progresses to active-assistive and then active ROM
• Weight-bearing status depends on fracture type and fixation method
• Physical therapy integral to outcome

8. Complications to Monitor

• Rockwood and Green's Fractures in Adults, 10th ed. (2025) - Blocks 13, 14, 23
• Mulholland and Greenfield's Surgery: Scientific Principles and Practice, 7th ed. - pp. 1403-1407
• Campbell's Operative Orthopaedics, 15th ed. (2026) - Box 59.7, Block 28, 31, 33
• Miller's Review of Orthopaedics, 9th ed. - Fracture Management section
• Pye's Surgical Handicraft, 22nd ed. - pp. 166-167

Management of Fractures

PART 1 - APLEY'S SYSTEM OF ORTHOPAEDICS AND FRACTURES (Solomon, Warwick & Nayagam, 9th ed.)

A. REDUCE

When to Reduce

• Unacceptable shortening
• Rotational deformity (never acceptable - even a few degrees cause functional loss)
• Significant angular deformity, especially near joints
• Intra-articular fractures (require anatomical reduction to prevent arthritis)

How to Reduce

• The standard first approach
• Performed under adequate analgesia or general/regional anesthesia
• Steps:
  1. Traction along the long axis of the limb - disimpacts the fragments
  2. Reverse the mechanism of injury - corrects the deformity
  3. Hold while immobilization is applied
• Requires two people: one for traction, one for counter-traction; a third to apply the cast
• Confirmed by post-reduction radiographs in two planes

• Closed reduction fails or is unacceptable
• Soft tissue is interposed between fragments
• Articular fractures requiring anatomical precision (e.g. tibial plateau, distal radius)
• Fractures that cannot be held by closed means
• Pathological fractures
• Multiple fractures in polytrauma

B. HOLD (Immobilization)

1. Plaster of Paris (POP) / Casting

• Most common method of immobilization
• Rules of casting (Apley's):
  • Must immobilize the joint above and below the fracture (to neutralize muscle pull)
  • Must not be applied circumferentially in the first 48-72 hours (risk of compartment syndrome from swelling) - use a slab initially
  • Padding under the cast (especially over bony prominences)
  • Mold the cast to the limb anatomy to prevent re-displacement
  • Neurovascular status must be checked after application
  • Patient must be warned of danger signs: increasing pain, numbness, tingling, inability to move fingers/toes

2. Traction

• Traction is a form of continuous reduction and immobilization simultaneously
• Patient nursed in bed for weeks - carries risks of immobility (DVT, pressure sores, chest infection)
• Largely replaced by operative fixation in modern practice

3. Functional Bracing

• Fracture brace (e.g. Sarmiento brace for tibial/humeral shaft fractures)
• Allows joint movement while maintaining fracture alignment
• Uses soft tissue and hydrostatic pressure within the limb to stabilize the fracture
• Applied once initial swelling subsides

4. External Fixation

• Pins inserted into bone above and below the fracture, connected by an external frame
• Indications (Apley's):
  • Open fractures with severe soft tissue injury
  • Comminuted, unstable fractures
  • Infected fractures
  • Periarticular fractures
  • Pelvic ring fractures (temporary stabilization, "damage control")
  • Burns over fracture site
  • Limb lengthening (Ilizarov method)
• Allows wound access, dressing changes, and soft tissue management
• Risk of pin-site infection

5. Internal Fixation

1. Anatomical reduction of fragments
2. Stable fixation (absolute or relative) to fulfill biomechanical demands
3. Preservation of blood supply to bone and soft tissues
4. Early active mobilization and rehabilitation

C. EXERCISE (Rehabilitate)

• Begin as early as possible
• Joints not immobilized must be exercised from Day 1 (prevents stiffness)
• Once fracture heals: progressive active exercises, muscle strengthening, proprioception training
• Weight-bearing: graduated, as healing progresses
• Physiotherapy: essential, especially in elderly patients prone to joint stiffness and muscle wasting

PART 2 - MAHESHWARI'S TEXTBOOK OF ORTHOPAEDICS (J. Maheshwari & Vikram A. Mhaskar, 5th ed.)

A. DIAGNOSIS AND INITIAL ASSESSMENT

1. Clinical diagnosis: Pain, swelling, deformity, abnormal mobility, crepitus, loss of function
2. Neurovascular assessment: Pulses, sensation, motor power distal to fracture - documented BEFORE and AFTER any manipulation
3. Radiological diagnosis:
   • Two views (AP and lateral) mandatory
   • Two joints: include the joints above and below
   • Two sides: contralateral limb for comparison in children
   • Two occasions: repeat X-rays at 7-10 days to detect re-displacement under cast

B. METHODS OF REDUCTION

1. Manipulative (Closed) Reduction

• Under local haematoma block, sedation, or general anaesthesia
• Traction in line of the limb disengages the fragments
• Reverse the deforming force
• Mould the soft tissue and periosteum around the fragments
• Confirmed by X-ray

• Fractures with minimal displacement
• Impacted fractures in acceptable position
• Fractures of small bones (e.g. toes)

2. Open Reduction

• Under general or regional anesthesia
• Direct visualization and reduction of fracture
• Always followed by internal fixation
• Indications:
  • Failure of closed reduction
  • Articular fractures
  • Pathological fractures
  • Fractures with neurovascular involvement
  • Polytrauma (early total care)
  • Femoral neck fractures (to restore blood supply)

C. METHODS OF RETENTION

1. Plaster of Paris

• Most economical and widely used method
• Types: Slab (3/4 cast, used acutely) and Full circular cast (applied after swelling subsides, at 7-10 days)
• Principles (Maheshwari):
  • Three-point fixation: two points on one side, one on the other - to hold the fracture angulated in the correct direction
  • Immobilize one joint above and below
  • Adequate padding (1-2 layers of cotton wool)
  • Apply in correct position of function (in case stiffness results)
  • Regular follow-up X-rays to detect loss of position

2. Traction

• Moleskin or Elastoplast applied to skin
• Maximum weight: 4-5 kg
• Used temporarily; for children; Pugh's traction, Buck's traction

• Steinmann pin through tibia (for femur fractures) or calcaneum (for tibia fractures)
• Weight: 1/7 of body weight
• Overhead olecranon traction for humeral shaft fractures
• Fixed traction (Thomas splint) vs. sliding/balanced traction (Pearson knee piece attachment)
• Thomas Splint: the classic device for femoral shaft fractures; ring around the upper thigh; fixed traction using a cord tied to the end of the splint

3. Functional Bracing (Sarmiento)

• Patented technique using a close-fitting thermoplastic brace
• Used for mid-shaft tibial and humeral fractures
• Allows adjacent joint mobility; hydrodynamic effect maintains alignment

4. External Fixation

• Unilateral fixators: AO, Orthofix, Monotube
• Circular fixators: Ilizarov - for complex fractures, non-union, bone defects, limb lengthening
• Pin tracks must be cleaned daily; pin-site infection is the main complication
• Indications same as outlined above

5. Internal Fixation (ORIF)

• Kirschner wires (K-wires): small bones, percutaneous
• Rush nails / Enders nails: flexible, multiple; used for osteoporotic fractures
• Interlocking IM nail (Kuntscher nail, AO IM nail): for femoral, tibial, humeral shaft fractures; can be locked proximally and distally to prevent rotation and shortening

• Plates: Compression plates (DCP), Locking compression plates (LCP), Buttress plates, Neutralization plates
• Screws: Cortical screws, cancellous screws, lag screws, locking screws
• Tension band wiring: for olecranon, patella

• Dynamic Hip Screw (DHS): for intertrochanteric fractures of femur
• Dynamic Condylar Screw (DCS): for subtrochanteric and distal femoral fractures
• Proximal Femoral Nail (PFN): for trochanteric and subtrochanteric fractures

D. REHABILITATION (Maheshwari)

• Begins immediately from the day of fracture fixation
• Phase 1 (Acute, 0-2 weeks): Elevation, active movements of non-immobilized joints, isometric exercises of immobilized muscles, pain control
• Phase 2 (Sub-acute, 2-6 weeks): Passive and active assisted ROM, non-weight bearing mobilization
• Phase 3 (Fracture healed): Active ROM, progressive resistance exercises, proprioception, full weight bearing
• Maheshwari emphasizes the importance of occupational therapy for upper limb fractures and physiotherapy for lower limb fractures

PART 3 - JOHN CRAWFORD ADAMS' OUTLINE OF FRACTURES (12th ed., revised by David L. Hamblen & J. R. A. Simpson)

A. GENERAL PRINCIPLES OF TREATMENT

• The type of fracture (stable vs. unstable)
• The site of fracture
• The age and general health of the patient
• Available facilities and expertise
• Associated injuries

B. METHODS OF TREATMENT

1. Conservative Treatment (Non-Operative)

• For fractures that are undisplaced or minimally displaced
• Plaster cast or splint
• Examples: undisplaced radial head fracture, undisplaced metacarpal fractures

• Standard treatment for most displaced closed fractures
• The plaster must be well-molded and extend to the joint above and below
• Risk of re-displacement must be monitored with serial X-rays

• When a cast cannot control the fracture
• Femoral shaft (Hamilton Russell traction, Thomas splint with fixed traction)
• Tibial fractures (calcaneal pin traction)

• Some fractures are best treated by early functional use
• E.g. fractures of the clavicle, many metacarpal fractures, most vertebral compression fractures
• Early movement prevents joint stiffness; mild deformity is acceptable if function is good

2. Operative Treatment

• Fracture reduced by closed means, fixation applied percutaneously or through small incisions
• Less soft tissue disruption than open reduction
• Examples: distal radial fractures (K-wires), femoral neck fractures (cannulated screws), intertrochanteric fractures (DHS)

• Direct exposure, reduction under vision, rigid fixation
• Advantages (Adams):
  • Accurate reduction (especially articular)
  • Stable fixation allows early mobilization
  • Shorter hospital stay
  • Avoids problems of prolonged traction/casting
• Disadvantages:
  • Risk of infection
  • Anaesthetic risk
  • Devascularization of fragments
  • Implant failure, stress shielding, need for second operation for removal

• For open fractures with soft tissue involvement
• Allows wound management without compromising fracture stability

C. SPECIAL CONSIDERATIONS - OPEN FRACTURES (Adams)

1. Emergency measures at scene: Sterile dressing, splintage, analgesia, IV access
2. In hospital:
   • Tetanus prophylaxis (toxoid + immunoglobulin if not immunized)
   • IV antibiotics: Cephalosporin (Grade I-II); add metronidazole (Grade III); add aminoglycoside for highly contaminated wounds; continue for 72 hours post-debridement
   • Thorough wound debridement in theatre under general anaesthesia - within 6 hours ideally
   • Removal of all foreign material, devitalized tissue, and contaminated bone
   • Copious lavage (pulse irrigation with normal saline 9 litres for Grade III)
   • Wound is usually left open (except Grade I which may be closed primarily)
   • Fracture stabilization: external fixation or IM nailing preferred over plates
   • Definitive wound closure at 48-72 hours (delayed primary closure or split skin graft or flap)
3. Second-look surgery: at 48-72 hours for re-debridement if needed
4. Plastic surgery collaboration: for Grade IIIb/c - free flap or local flap coverage

D. COMPLICATIONS OF FRACTURES (Adams)

• Haemorrhage (internal and external)
• Injury to adjacent structures: arteries, veins, nerves, viscera, skin
• Shock (hypovolaemic)

• Compartment syndrome
• Fat embolism syndrome (especially femoral and tibial fractures)
• Deep vein thrombosis (DVT)

COMPARISON SUMMARY TABLE

KEY TEACHING POINTS COMMON TO ALL THREE BOOKS

1. Not every fracture needs reduction - position must be "acceptable," not always "perfect"
2. The aim is function, not radiological perfection
3. Immobilization must include the joint above and below the fracture
4. Rotational deformity is never acceptable - must be corrected
5. Neurovascular status must be documented before and after every manipulation
6. Open fractures are surgical emergencies - debridement within 6 hours, antibiotics early, wound left open
7. Compartment syndrome is a limb-threatening emergency requiring urgent fasciotomy
8. Rehabilitation begins on Day 1 - non-immobilized joints are moved immediately
9. AO principles: anatomical reduction, stable fixation, blood supply preservation, early mobilization
10. Intramedullary nailing is the gold standard for femoral, tibial, and humeral shaft fractures in adults

• Apley's System of Orthopaedics and Fractures, Solomon, Warwick & Nayagam, 9th ed. (CRC Press, 2010)
• Maheshwari's Textbook of Orthopaedics, J. Maheshwari & Vikram A. Mhaskar, 5th ed. (Jaypee Brothers)
• Outline of Fractures, John Crawford Adams, revised by Hamblen & Simpson, 12th ed. (Churchill Livingstone)
• Rockwood and Green's Fractures in Adults, 10th ed. (2025) - for supplementary evidence
• Mulholland and Greenfield's Surgery, 7th ed. - for open fracture and compartment syndrome evidence

Management of Fractures

Based on Apley's System of Orthopaedics | Maheshwari's Textbook of Orthopaedics | John Crawford Adams' Outline of Fractures

CORE PRINCIPLE

"REDUCE - HOLD - REHABILITATE" (Apley's) / "Diagnose - Reduce - Retain - Rehabilitate" (Maheshwari) / "Union in optimum position with minimum complications" (Adams)

STEP 1: INITIAL ASSESSMENT

Not all fractures need reduction - undisplaced, impacted, or stable fractures may only need immobilization.

STEP 2: REDUCTION

A. Closed (Manipulative) Reduction

• Standard first-line approach
• Under local haematoma block, sedation, or general/regional anaesthesia
• Three steps:
  1. Traction in the long axis of the limb - disimpacts fragments
  2. Reverse the mechanism of injury - corrects deformity
  3. Mould soft tissue envelope around reduced fragments
• Requires three people: one for traction, one for counter-traction, one to apply the cast
• Confirmed by post-reduction X-ray in two planes

B. Open Reduction (Operative)

• Failure of closed reduction
• Soft tissue interposition between fragments
• Articular/intra-articular fractures (require anatomical precision)
• Fractures associated with neurovascular injury
• Pathological fractures
• Polytrauma / multiple fractures
• Femoral neck fractures (to restore blood supply)

STEP 3: HOLD (Immobilization / Retention)

1. Plaster of Paris (POP) / Cast

• Apply a slab (back-slab/3-quarter cast) initially for first 48-72 hours - allows for post-injury swelling; full circular cast applied after swelling subsides (~7-10 days)
• Must immobilize the joint above AND below the fracture
• Adequate padding (especially over bony prominences)
• Three-point fixation principle: two contact points on one side, one on the opposite
• Warn the patient: increasing pain, numbness, tingling, cold/blue fingers or toes = emergency
• Serial X-rays under cast to detect re-displacement

2. Traction

• Thomas splint with fixed traction: femoral shaft fractures
• Hamilton Russell traction: balanced traction for femoral fractures
• Overhead olecranon traction: humeral shaft fractures
• Calcaneal pin traction: tibial fractures

3. Functional Bracing (Sarmiento Brace)

• Close-fitting thermoplastic brace applied after initial swelling settles
• Allows adjacent joint movement
• Hydrostatic pressure of soft tissues maintains fracture alignment
• Used for: mid-shaft tibial and humeral shaft fractures

4. External Fixation

• Open fractures with severe soft tissue injury
• Highly comminuted/unstable fractures
• Infected fractures or fractures with burns
• Pelvic ring fractures (temporary damage-control stabilization)
• Limb lengthening (Ilizarov ring fixator)

• Main complication: pin-site infection - requires daily pin-site care

5. Internal Fixation (ORIF / CRIF)

1. Anatomical reduction of fracture fragments
2. Stable fixation - absolute or relative, to meet biomechanical demands
3. Preservation of blood supply to bone and surrounding soft tissues
4. Early active mobilization and rehabilitation

STEP 4: MANAGEMENT OF OPEN FRACTURES

Gustilo-Anderson Classification

Management Sequence (Adams + Apley's)

• Sterile dressing over wound; do NOT remove dressing repeatedly
• Splintage; IV access; analgesia; photograph wound

• IV antibiotics: start within 3 hours of injury
  • Grade I-II: Cephalosporin (e.g. cefazolin 1g IV 8-hourly)
  • Grade III: Add metronidazole (anaerobic cover) + aminoglycoside (Gram-negative cover)
  • Continue for 72 hours post-debridement (not beyond)
• Tetanus prophylaxis (toxoid ± immunoglobulin)
• Neurovascular assessment and documentation

• Thorough wound debridement and excision to healthy bleeding margins
• This is one of the most difficult operations - must NOT be delegated to inexperienced staff
• Remove: all foreign material, devitalized tissue, contaminated/loose bone fragments
• Copious lavage: 3 litres (Grade I-II), 6-9 litres (Grade III) pulsed saline irrigation
• Wound left OPEN except Grade I (which may be closed primarily)
• Fracture stabilization: external fixation or locked IM nail preferred over plates
• Plastic surgery team involvement from the outset (Grade IIIb/c)

• Re-inspect wound; further debridement if needed
• Definitive wound closure: delayed primary closure / split skin graft / local or free flap

STEP 5: EMERGENCY COMPLICATIONS TO RECOGNIZE IMMEDIATELY

Compartment Syndrome

• Cause: Rising pressure within a closed fascial compartment reduces tissue perfusion
• Classic sign: Pain out of proportion to injury; pain on passive stretch of muscles in that compartment
• Diagnosis: Compartment pressure measurement; if Delta-P (Diastolic BP - Compartment Pressure) < 30 mmHg = fasciotomy
• Important: Presence of distal pulse does NOT rule out compartment syndrome
• Treatment: Emergency fasciotomy - release ALL compartments of the affected segment

Vascular Injury

• Acutely ischemic limb with fracture = major surgical emergency
• Fracture/dislocation must be rapidly reduced first (often restores circulation)
• If not: emergent combined vascular + orthopaedic procedure; temporary shunt if needed
• Bony stability must be obtained at correct length before definitive vascular repair

STEP 6: REHABILITATION

COMPLICATIONS OF FRACTURES

10 GOLDEN RULES OF FRACTURE MANAGEMENT

1. Not every fracture needs reduction - position must be "acceptable," not always "perfect"
2. The goal is function, not radiological perfection
3. Rotational deformity is never acceptable - always correct
4. Immobilization must cross the joint above and below the fracture
5. Document neurovascular status before and after every manipulation
6. Open fractures are surgical emergencies - antibiotics within 3 hours; debridement within 6 hours; wound left open
7. Compartment syndrome demands immediate fasciotomy - do not wait for pulse to disappear
8. Rehabilitation begins Day 1 - move all non-immobilized joints
9. IM nailing is the gold standard for femoral, tibial, and humeral shaft fractures
10. AO principles: Reduction + Stable fixation + Blood supply preservation + Early mobilization

• Apley's System of Orthopaedics and Fractures - Solomon, Warwick & Nayagam, 9th ed.
• Maheshwari's Textbook of Orthopaedics - J. Maheshwari & V. A. Mhaskar, 5th ed.
• Outline of Fractures - John Crawford Adams, revised Hamblen & Simpson, 12th ed.