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Long Bone Fractures
Treatment

Fractures of the "long bones" are one of the most common injuries associated with a variety of accidents. Long bones are long, cylindrical and hollow in the middle, and have a joint at each end. These bones can be injured (fractured) at any place along the course of the bone. This discussion will be directed to that portion of the bone that does not involve the joint. Long bones can be treated with a cast (on the outside of the skin), by attaching a device to the bone (plate or external fixator) or by inserting a rod inside of the bone (intramedullary nail). The femur can also be treated with traction by pulling on the leg with a weight to align the broken bone.

Anatomy

  • The long bones are designed to provide structural support: Various muscles attach to these bones to allow movement of the arms and legs. Nerves, arteries and veins lie along the course of the bones and, therefore, fracture of these bones may compromise these structures causing loss of function and blood supply (Figures 1,2,3,4,5,6)
    1. Humerus (arm). The humerus extends from the shoulder to the elbow
    2. Radius and ulna (forearm). The radius extends from the elbow to the thumb side of the wrist and rotates around the ulna when the hand moves from palm up to palm down. The ulna extends from the little finger side of the forearm to the tip of the elbow (olecranon). A fibrous band extends between the length of the radius and ulna
    3. Femur (thigh). The femur is the longest bone in the body and extends from the hip socket to the knee
    4. Tibia and fibula (lower leg). The tibia is the largest of the bone of the lower leg, extends from the knee to the ankle and supports the body weight. The smaller fibula does not support much body weight and is primarily for muscle attachment
    5. Metacarpals (hand). The metacarpals are the thin tubular bones in the palm of the hand
    6. Metatarsals (feet). The metatarsals are the thin tubular bones in the forefoot
    7. Phalanges (fingers and toes). The phalanges are the small bones of the fingers and toes
Figure 1 - Bones of the arm. © T. Graves Figure 2 - Bones of the leg. © T. Graves
Figure 3 - Arteries of the arm, © T. Graves Figure 4 - Arteries of the leg. © T. Graves
Figure 5 - Nerves of the arm. © T. GravesFigure 6 - Nerves of the leg, © T. Graves

Pathology

Trauma is the main cause of fractures. Occasionally bone disease or tumor may weaken a bone so that only minimal injury results in a fracture (Figure 7)

  • A fracture may occur without deformity (a non-displaced fracture)
  • The bone may be bent or angled
  • The bone fragments may be displaced
  • The bone fragments may be angled and displaced
  • The bone may be broken and may not penetrate the skin (closed fracture) or may penetrate the skin (open fracture)
  • The bone may be in two pieces (simple fracture)
  • The bone may be in multiple pieces (comminuted fracture)
Figure 7 - Various types of fractures demonstrated using the femur. © T. Graves

History and Examination

  • Almost always the patient has had an accident. This may very from a slip and fall to a high speed motor vehicle accident
  • Depending on the severity of the accident, there may be associated injuries that may be life threatening and be of greater concern to the attending physicians than the fractures
  • The patient will complain of pain in the area of the fracture
  • There is associated tenderness and swelling, but occasionally these signs may not be present
  • The limb may be angulated at the site of the fracture
  • The bone may be punctured through the skin (open fracture)
  • If the artery is also injured, the limb may be cold or blue
  • If a nerve is also injured, there may be paralysis of muscles distal (farther down the limb) to the injury
  • An attempt to move the bone may result in a grating sensation (crepitus)
  • Compartment syndrome - With associated hemorrhage, crushing injury to the adjacent muscles or injury to vessels there may be severe swelling with an increase in tissue pressure. The circulation may be cut off leading to lack of oxygen to the muscles and result in further swelling with a potential for loss of limb
  • Though rare, the patient may have a fat embolism. Fat in the marrow of the fractured bone may get into the blood circulation and go to the brain, lung and or kidney. This may result in an unexplained stroke, difficulty in breathing or fat in the urine
  • Because long bone fractures are frequently associated with severe , the patient may exhibit evidence of shock, breathing difficulty and/or loss of consciousness

Tests

  • Plain X-rays are primarily used to evaluate the fracture
  • Occasionally, a CT scan of the fracture site is required to see all the fracture fragments and the relationship the fragments to each other. This is usually use in comminuted fractures in which multiple fragments are present
  • Very occasionally, an arteriogram will be necessary for an associated vascular problem

Indications and Contraindications

  • Treatment of the fracture is always necessary, however, when the fracture is treated depends on the condition of the patient
  • The major contraindications to immediate treatment are:
    1. Other life threatening injuries that must be treated first in order to save the patient's life
    2. Associated medical conditions that are not related but which must be treated before an anesthetic can be given to the patient such as significant heart disease

Surgical Procedures

When long bones are broken, correct alignment needs to be achieved. The location of the fracture along the course of the bone will result in a deformity because of the force of the and the pull of the muscles surrounding the fracture. Correct alignment of the fracture may be achieved by:

  • Cast
    1. A cast may be made of plaster of Paris or a synthetic material. The synthetic material is made of a plastic that is lightweight and comes in several colors
    2. If the fracture is in good position the fracture may be casted (immobilized) with only sedation (See Anesthesia)
    3. Most patients require a general anesthetic or regional block (See Anesthesia) because the fracture has to be manipulated (closed reduction). Traction is usually applied to the limb while the orthopedic surgeon 'molds' the fragments into alignment
    4. With the fracture held in alignment, a padding material is rolled over the limb following which the cast material is rolled over the limb and allowed to set into a form fitting rigid mold
    5. The cast is worn for a variable length of time depending on the bone fractured. The usual time is about six weeks but may be shorter or longer depending on the evidence of healing
    6. The cast may need to be changed during treatment. On occasion the fracture may require another manipulation to better align the fracture
    7. X-rays may be taken through the cast to determine proper alignment and amount of healing
    8. The cast is removed when there is good evidence of healing
    9. A cast may also be used after surgical reduction of a fracture to help support bony alignment
  • Reduction with External Fixation (Closed or Open) (Figures 8 and 9)
    1. The procedure may be carried out under local anesthesia and sedation but more commonly under general anesthesia
    2. Pins are placed into the bone through the skin a short distance away from the fracture. An external fixator composed of rods and rod holders is applied to these pins to stabilize the fracture (closed reduction with external fixation)
    3. No cast is necessary because the bones are held rigidly by the apparatus
    4. Since the skin is not covered with a cast, the skin can be cared for in the same as the skin of an open wound without a fracture
    5. At times, the fracture site will have to be opened and the bone manipulated manually to align the fracture prior to fixation with an external apparatus (open reduction with external fixation)
    6. The fixation device is removed when the fracture is healed
Figure 8 - Fracture of the wrist held by an external fixator. Pins are placed in radius and first metacarpal bones. The interconnecting rods are not metallic and do not show on X-ray. Courtesy F. Maibauer, MDFigure 9 - Fracture of the tibia and fibula. Tibial fracture is held by an external fixator. Pins are placed above and below the fracture. The interconnecting rods do not show on X-ray. Courtesy F. Maibauer, MD
  • Internal Fixation
    1. Internal fixation is usually carried out under general anesthesia but a spinal anesthetic may be used for leg fractures
    2. Internal fixation can be carried out with screws, bone plates or intramedullary rods which are usually made of stainless steel or titanium
    3. There are three basic types of internal fixators: screws, plates held with screws and intramedullary rods. The fixator used is determined by the orthopedic surgeon so as to best align and hold the fracture. For example,
    • Screws may be used to hold overlapping bone fragments
    • Plates and screws to align non-overlapping bone (Figures 10 and 11)
    • Intramedullary rods, special rods placed in the medullary (marrow) canal of the bone, may be used when there are multiple bone fragments (Figure 12)
    1. When using screws or screws and plates, the incision is placed over the fracture site. The length of the incision is long enough to accommodate the surgical procedure. The skin, fat muscles, tendons, nerves, and blood vessels are retracted (moved out of the way). The fracture is identified and a plate is screwed onto the surface of the bone to secure the bone in as close to normal position as possible
    2. When using an intramedullary rod an additional incision is placed at one end of the long bone. A drill is used to put a hole through end of the bone. A rod is chosen just smaller than the inside diameter of the intramedullary canal and is pounded down the intramedullary canal of the bone fragments crossing the fracture to stabilize the bone
    3. Occasionally, a bone graft is required to increase the volume of bone and stimulate the bone's ability to create new bone. The graft can be obtained from a bone bank (sterilized donor bone) or taken from the patient. The patient donator site is usually from the iliac crest (hip bone)
    4. The fractured bone is checked with an X-ray or with fluoroscopy (portable X-ray machine with video)
    5. Following placement of the internal fixator the surgical wounds are closed with sutures or staples. A soft dressing or cast is applied to protect limb
Figure 10 - Fracture of the radius and ulna held by plates and screws. Courtesy F. Maibauer, MDFigure 11a - Fracture of the tibia held with plate and screws. Additional screws used to hold bone fragments at the ankle. Courtesy F. Maibauer, MD
Figure 11b - Healed fracture seen in A. Courtesy F. Maibauer, MD

Figure 12 - Fracture of the tibia and fibula. Tibia held by an intramedullary rod. Courtesy F. Maibauer, MD

Complications

  • Malposition. The bone alignment is not as straight as it was
  • Delayed union. The fracture takes longer to heal than expected
  • Non-union. Failure of the fracture to heal
  • Infection
  • Injury to artery or nerve may occur but is infrequent
  • Muscle and skin adhesions and adjacent joint stiffness are frequently observed and treatment with therapy and exercise follows the healing of the bone
  • Anesthetic complications are similar to other surgical procedures
  • Breathing problems, heart problems, stroke, paralysis and death may occur but are rare
  • Compartment syndrome - see above

Post-operative Care

  • The patient may be able to go home with pain medication following placement of a cast if there are no associated medical problems
  • With a surgical procedure the patient is usually kept in hospital at least one day and may be there for a prolonged period of time depending on the severity of the fracture or associated injury
  • The limb is kept elevated for several days to reduce swelling
  • The patient returns to the surgeon's office at regular intervals for follow up
  • With cast immobilization, the cast is removed after the fracture heals: for a radius, about 6 weeks and a tibia may require six months. Each bone has its own average time to heal
  • Pin fixation may require the pins to be removed because they migrate (move within the bone or into soft tissue) or break
  • Plates, screws, and rods may require removal if they become symptomatic - ache, irritate the overlying soft tissue, or are prominent under the skin