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  1. Guidelines for emergency physicians.

  2. Physician surgeon medical emergency

  3. Technologists / Casting and Splinting

  4. Orthopedicians
Traumatic fractures
  1. What must a medical emergency physician or orthopedician know about fracture fixation?
    Here are guidelines from Doctor Asif Qureshi.

  2. How do you fix a traumatic fracture in the medical emergency department?
    Here are further guidelines.

  3. What describes the patient?
    Here are further guidelines.

  4. How do you proceed if the patient is hemodynamically stable (meaning consciousness, pulse, and blood pressure are normal, without bleeding)?
    Here are further guidelines.

  5. What describes the fracture?
    Here are further guidelines.

  6. What are orthopedic immobilization techniques?
    Here are further guidelines.

  7. What is on the list of orthopedic implants?
    Here are further guidelines.

  8. What is the open reduction of a fracture?
    Here are further guidelines.

  9. What is the closed reduction of a fracture?
    Here are further guidelines.

  10. What is the internal fixation of a fracture?
    Here are further guidelines.

  11. What type of immobilization does this fracture need?
    Here are further guidelines.

  12. What type of fixation does this fracture need?
    Here are further guidelines.

  13. What are Fractures?
    Here are further guidelines.

  14. What causes a fracture?
    Here are further guidelines.

  15. What are common types of fractures?
    Here are further guidelines.

  16. What are common types of fractures?
    Here are further guidelines.

  17. How is a fracture diagnosed?
    Here are further guidelines.

  18. What are the most common causes of fractures?
    Here are further guidelines.

  19. How long does it take a fracture to heal?
    Here are further guidelines.

  20. How are fractures treated?
    Here are further guidelines.

  21. What is the difference between internal fixation and external fixation of a fracture?
    Here are further guidelines.

  22. When will you do external fixation of a fracture?
    Here are further guidelines.

  23. How will you do external fixation of a fracture?
    Here are further guidelines.

  24. When will you do internal fixation of a fracture?
    Here are further guidelines.

  25. How will you do internal fixation of a fracture?
    Here are further guidelines.

  26. Where and when will you use a nail, screw, rod, plate in fixation of a fracture?
    Here are further guidelines.

  27. What are common types of fractures?
    Here are further guidelines.

  28. Skeletal System
  29. How many human body systems are there?
    Here are further guidelines.

  30. What are the names of human body systems?
    Here are further guidelines.

  31. How many bones, muscles, internal organs, and cells does a mature human have?
    Here are further guidelines.

  32. How many human body bones are there in one matured human being?
    Here are further guidelines.

  33. What are the names of human body bones?
    Here are further guidelines.

  34. How many human body muscles are there in one matured human being?
    Here are further guidelines.

  35. What are the names of human body muscles?
    Here are further guidelines.

  36. How many human anatomy categories are there?
    Here are further guidelines.

  37. What should you know about human anatomy by category?
    Here are further guidelines.

  38. How many human body internal organs are there in one human being?
    Here are further guidelines.

  39. What are the names of human body internal organs?
    Here are further guidelines.

Skeletal System
How many human body systems are there?

What are the names of human body systems?
Here are further guidelines.

How many bones, muscles, internal organs, and cells does a mature human have?
Bones: 206
Internal organs (main): 22
Muscles: 600
100 trillion cells

How many human body bones are there in one matured human being?

What are the names of human body bones?

Here are further guidelines.

How many human body muscles are there in one matured human being?
600 muscles

What are the names of human body muscles?
Here are further guidelines.

Human anatomy by category

How many human anatomy categories are there?

What should you know about human anatomy by category?
Here are further guidelines.

How many human body internal organs are there in one human being?
22 internal organs

What are the names of human body internal organs?
Here are further guidelines.

Traumatic fractures
How do you fix a traumatic fracture in the medical emergency department?

What describes the patient?
1. Hemodynamically unstable. Treatment: First bring consciousness, pulse, and blood pressure back to normal.
2. Hemodynamically stable. Means consciousness, pulse, and blood pressure are normal, without bleeding.

How do you proceed if the patient is hemodynamically stable (meaning consciousness, pulse, and blood pressure are normal, without bleeding)?
Always remember to Xray the traumatic site before fixing it.
Also Xray the traumatic site after fixing it.

What describes the fracture?
1. Green stick
2. Spiral
3. Comminuted
4. Transverse
5. Compound
6. Vertebral Compression

Types of skull fractures

The type of skull fracture depends on the force of the blow, the location of the impact on the skull, and the shape of the object making impact with the head.

A pointier object is more likely to penetrate the skull than a hard, blunt surface, such as the ground. Different types of fractures lead to differing levels of injury and trauma. See a body map of the skull.

Closed fracture
v With a closed fracture, also called a simple fracture, the skin that covers the fracture area isn’t broken or cut.

Open fracture
v Also known as a compound fracture, an open fracture occurs when the skin is broken and the bone emerges.

Depressed facture

This refers to a fracture that causes the skull to indent or extend into the brain cavity.
v Basal fracture

A basal fracture occurs in the floor of the skull: the areas around the eyes, ears, nose, or at the top of the neck, near the spine.

Other types

In addition to the above types, fractures can also classify as:
linear (in a straight line)
comminuted (broken into three or more sections)

•Simple – break in bone, no damage to skin
•Linear – break that forms in a thin line (most common)
•Depressed – depression of bone toward brain
•Compound – bone splinters and breaks skin

What are orthopedic immobilization techniques?

Orthopedics addresses problems of the musculoskeletal system by both surgical and nonsurgical means. Orthopedic surgeons treat musculoskeletal trauma, fractures, sports injuries, the spine, degenerative diseases, bone infections, tumors, and congenital disorders.

In most trauma and fracture cases, the injured area will be immobilized to provide therapeutic healing over a sustained period. Orthopedics uses immobilization equipment and strategies to treat trauma, injuries, and diseases.

These devices help keep the affected joints or bones in place and prevent harmful or painful movements while the area is healing. Thus, it is crucial to use dependable, high-tech orthopedic immobilization equipment and devices during your recovery.

Types of Immobilization Devices

The cast, splint, or brace will provide support to the injured joint from both above and below when an arm, hand, leg, or foot requires immobilization. Hip, upper thigh, shoulder or upper arm injuries require a cast that encloses the body and extends up or down the injured arm or leg.

Casts, Splints, Braces

These devices support and protect broken bones, dislocated joints and injured tissues. Motion is restricted in order to allow injured areas to heal and to reduce pain, swelling and muscle spasms. Splints and casts are also used after surgery to repair broken and damaged bones, tendons and ligaments.

Splints are available for every joint in the body and are used for a wide variety of orthopedic injuries and postoperative immobilization. Fractures and sprains, for example, are splinted to make room for the inevitable swelling that accompanies these injuries. Uncontrolled swelling can cause compartment syndrome, which can damage the neurovascular system in the affected area.

Casts, on the other hand, do not accommodate for swelling and are most often used after the acute injury phase is over, when a splint may be replaced with a cast for longer-term immobilization and healing.


Orthotic braces, or orthoses, are used to provide support to a weakened area of the body. They are usually worn for a short period of time after an injury or surgery. Sometimes braces are used to correct chronic conditions. Some common conditions for which long term-use of an orthosis may be prescribed by your physician include scoliosis, osteoarthritis, back pain and drop foot.

Cervical collars

Cervical (neck) collars are used to support the neck and shoulders. Rigid collars are usually constructed of plastic. They hold the head and neck firmly in place. They are used after major surgery or serious injury, such as a broken neck. Cervical collars are sometimes used to support the neck for a short time. They may be rigid, or soft and made from felt, foam, or rubber. Soft collars allow limited movement of the neck.

Clavicle Orthoses

Collarbones can be injured or broken through car accidents, falls, or various sports injuries. Acromioclavicular joint injury, thoracic outlet syndrome, infected clavicle, bone cancer, and joint arthritis are some other clavicle injuries. Even sleeping in the wrong position can be traumatic to the clavicle. Specialized clavicle orthoses are effective means of protection and support through the healing process.

Posture-Correcting Orthoses

Posture braces are designed to help correct posture by pulling the shoulders back and away from the ears. This aligns the spine and prevents the shoulders from slumping forward. Posture braces can help with back pain, injury or incorrect posture.

Sleeves and Straps

Multiple-zoned orthopedic compression sleeves improve circulation, support muscle and ligament stability and aid in recovery. They help to ease the pain, protect fragile areas and prevent injuries to joints and muscles.

These sleeves fit the body, are breathable, and provide comfort during the day or night. Normal activities can be carried on comfortably when wearing these supportive sleeves.

Sleeves and orthopedic straps are available for wrists, elbows, thighs, knees, calves, and ankles.

Before applying any immobilization device, a qualified physician or health care professional should complete an injury evaluation, including a neurovascular assessment. An accurate diagnosis will inform the appropriate treatment plan, at which point the most appropriate immobilization device can be selected.

What is on the list of orthopedic implants?
  1. Austin-Moore prosthesis : for fracture of the neck of femur

  2. Baksi's prosthesis : for elbow replacement

  3. Charnley prosthesis : for total hip replacement

  4. Condylar blade plate : for condylar fractures of femur

  5. Ender's nail : for fixing inter-trochanteric fracture

  6. Grosse-Kempf (GK) nail : for tibial or femoral shaft fracture

  7. Hansson pin (or LIH for Lars Ingvar Hansson), a hook-pin used for fractures of the femoral neck.

  8. Harrington rod: for fixation of the spine

  9. Hartshill rectangle : for fixation of the spine

  10. Insall Burstein prosthesis : for total knee replacement

  11. Richard N.W. Wohns interspinous implant and implantation instrument : intended to be implanted between two adjacent dorsal spines

  12. Kirschner wire : for fixation of small bones

  13. Kuntscher nail : for fracture of the shaft of femur

  14. Luque rod : for fixation of the spine

  15. Moore's pin : for fracture of the neck of femur

  16. Neer's prosthesis : for shoulder replacement

  17. Rush nail : for diaphyseal fractures of long bone

  18. Smith Peterson (SP) nail : for fracture of the neck of femur

  19. Smith Peterson nail with McLaughlin's plate : for inter-trochanteric fracture

  20. Seidel nail : for fracture of the shaft of humerus

  21. Souter's prosthesis : for elbow replacement

  22. Steffee plate : for fixation of the spine

  23. Steinmann pin : for skeletal traction

  24. Swanson prosthesis : for the replacement of joints of the fingers

  25. Talwalkar nail : for fracture of radius and ulna

  26. Thompson prosthesis : for fracture of the neck of femur
Here are the questions you need to answer.
Is there a fracture?

What describes the fracture?

1. Green stick
2. Spiral
3. Comminuted
4. Transverse
5. Compound
6. Vertebral Compression

What is the open reduction of a fracture?
What is the closed reduction of a fracture?
What is the internal fixation of a fracture?
What type of immobilization does this fracture need?
What type of fixation does this fracture need?

Q: What are Fractures?
Q: What causes a fracture?
Q: What are common types of fractures?
Q: Where is the fracture?
Q: What are common types of fractures?
Q: How is a fracture diagnosed?
    Q: How do fractures or broken bones occur?
    Q: Is there a history of trauma or injury?
    Q: Where, when, and why did the injury occur?
    Q: What was the nature of the trauma or injury?
    Q: Did the person trip and fall, or did they pass out before the fall?
    Q: Where is the fracture?
Q: What are the most common causes of fractures?
Q: How long does it take a fracture to heal?
Q: How are fractures treated?
Q: What is the difference between internal fixation and external fixation of a fracture?
Q: When will you do external fixation of a fracture?
Q: How will you do external fixation of a fracture?
    Q: Will surgery be required for the external fixation?
    Q: What type of anesthesia will be used?
    Q: How is the surgery performed?
    Q: What can be expected after the surgery?
    Q: How long is the hospital stay?
    Q: How long will the pins and steel rods be required?
    Q: How will the pins and steel rods be removed?
Q: When will you do internal fixation of a fracture?
Q: How will you do internal fixation of a fracture?
Q: Where and when will you use a nail, screw, rod, plate in fixation of a fracture?
Understanding this is essential.

Normally, when an outside stress is applied to the bone, the bone "gives" and then returns to its normal shape when the stress stops. However, if the stress is too strong for the bone, the bone will crack or break. Bones that are weakened by disease are more likely to break.

What are the most common causes of fractures?
Trauma to the bone, like that caused by a fall or motor vehicle accident, is the number one cause of fractures. Osteoporosis, a disease that causes bone thinning, is a major contributor to fractures. Individuals with osteoporosis are more susceptible to bone fractures. Overuse or misuse of the bones can also cause fractures. This normally occurs among athletes. The column to the right has links to some of the more common causes of broken bones.

What are common types of fractures?
The most common types of fractures are:
* Closed or simple fracture: A break in the bone in which the skin is still intact.
* Open or compound fracture: A break in the bone in which the skin is perforated by the bone or by a blow at the time of the fracture.
* Segmental or multiple fracture: A break at two or more places on the same bone.
* Comminuted fracture: A break in which the bone is shattered into pieces.

The line of the fracture may be:
* Transverse: Forms a right angle with the axis of bone.
* Oblique: Runs slanted to the axis of the bone.
* Longitudinal: Runs along the line of its axis.


Dislocation is the displacement of a joint from its normal position, usually caused by a blow, fall or other trauma. In addition to displaced bones, there may be damage to the joint capsule and surrounding muscles, blood vessels and nerves. The symptoms include loss of motion, swelling and pain, and sometimes a joint visibly out of place.

Fractures, Dislocations, and Sprains: Epiphyseal disks (growth plates)

Most fractures result from a single application of significant force to otherwise normal bone. Pathologic fractures result from application of mild or minimal force to a bone weakened by a disorder such as cancer, cysts, or osteoporosis. Stress fractures (eg, metatarsal stress fracture—see Exercise and Sports Injury: Metatarsal Stress Fracture) result from repetitive application of force.


If Ca and vitamin D levels are adequate and bone tissue is healthy and the fracture edges are kept reasonably close to each other and with little or no relative motion, most fractures heal within weeks or months via remodeling. New tissue (callus) is produced within weeks, and bone reshapes at variable rates during the first weeks or months. Ultimately, optimal remodeling requires gradual resumption of normal motion and load-bearing stress. However, remodeling can be disrupted and refracture can occur if force is applied or the joint moves prematurely; thus, immobilization is usually needed.

Serious complications are unusual. Arteries are injured occasionally in closed supracondylar fractures of the humerus and femur but rarely in other closed fractures. Compartment syndrome or nerve injury may occur. Open fractures predispose to bone infection (see Infections of Joints and Bones: Osteomyelitis), which can be intractable. Fractures of long bones may release fat (and other marrow contents) that embolizes to the lungs and causes respiratory complications (see Pulmonary Embolism (PE): Tables). Fractures that extend into joints usually disrupt articular cartilage; misaligned articular cartilage tends to scar, causing osteoarthritis and impairing joint motion. Occasionally, fractures do not heal (called nonunion); rarely, nonunion occurs even when treatment is expeditious and correct. If the vascular supply is injured by the initial injury (such as a scaphoid fracture), aseptic necrosis may ensue even if the fracture was properly immobilized.

Symptoms, Signs, and Diagnosis

Pain is usually immediate. Swelling increases for several hours. Children may not exhibit significant soft-tissue swelling in the presence of a fracture (buckle [torus] fracture or greenstick fracture). Pain and swelling usually begin to resolve after 12 to 24 h; worsening pain after this period suggests compartment syndrome. Other symptoms and signs may include bone tenderness, ecchymosis, decreased or abnormal motion, deformity, and crepitation. With some fractures (eg, rib fractures), motion can be sensed by the patient and is described as a popping or cracking sensation.

Patients with findings that suggest fracture are examined for ischemia, compartment syndrome, and nerve injury. If a wound is close to a fracture, open fracture is assumed. Fractures are diagnosed by imaging, beginning with plain x-rays. If no fracture line is obvious, bone density, trabecular pattern, and cortical margins are examined for subtle clues to fracture. If a fracture is not visible on plain x-rays but is strongly suspected or if more detail is needed to guide treatment, MRI or CT is done. Some experts recommend imaging the joints proximal and distal to the fracture.

A fracture's appearance on x-rays can be described precisely using 5 terms:

Common types of fracture lines.

Transverse fractures are perpendicular to the long axis of bone. Oblique fractures occur at an angle. Spiral fractures result from a rotatory mechanism; on x-rays, they are differentiated from oblique fractures by a component parallel to the long axis of bone in at least 1 view. Comminuted fractures have > 2 bone fragments. Comminuted fractures include segmental fractures (2 separate breaks in a bone). Avulsion fractures are caused by a tendon dislodging a bone fragment. In impacted fractures, bone fragments are driven into each other, shortening the bone; these fractures may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex. Childhood fractures include torus fractures (buckling of the bone cortex) and greenstick fractures (cracks in only 1 side of the cortex).

Fig. 3
Spatial relationship between fracture fragments.
Spatial relationship between fracture fragments.

Distraction, displacement, angulation, or shortening (overriding) may occur. Distraction is separation in the longitudinal axis. Displacement is the degree to which the fractured ends are out of alignment with each other; it is described in millimeters or bone width percentage. Angulation is the angle of the distal fragment measured from the proximal fragment. Displacement and angulation may occur in the ventral-dorsal plane, lateral-medial plane, or both.

* Type of fracture line (see Fig. 2: Fractures, Dislocations, and Sprains: Common types of fracture lines.Figures)

* Location of fracture line
* Angulation
* Displacement (see Fig. 3: Fractures, Dislocations, and Sprains: Spatial relationship between fracture fragments.Figures) *
Open or closed
Location may be the bone's head (sometimes involving the articular surface), neck, or shaft (proximal, middle, or distal third).


Immediate treatment includes analgesics and, for suspected unstable fractures or fractures of long bones, splinting. Suspected open fractures require sterile wound dressings, tetanus prophylaxis, and broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside).

Rotational malalignment or significant angulation or displacement is corrected with reduction (realignment of bone fragments by manipulation). Exceptions include some diaphyseal fractures in children. In these fractures, remodeling gradually corrects some types of significant angulation, and end-to-end realignment of fractured bone fragments can stimulate bone growth, which may then be excessive.

Closed reduction (without skin incision) is done when possible; if not, open reduction (with skin incision) is done.

In open reduction and internal fixation (ORIF), fracture fragments are aligned and held in place using hardware. ORIF is usually indicated for the following:

* When an intra-articular fracture is displaced (to precisely align the joint cartilage) *

When ORIF has been shown to have better results for a particular type of fracture

* When closed reduction was ineffective *

When the fracture traverses a cancerous lesion (because normal bone healing does not occur) *

When prolonged immobility (required for callus formation and remodeling) is undesirable (eg, for hip fractures), because ORIF provides early structural stability, which facilitates mobilization

Surgery is required when injury to a major vessel is suspected (for vessel repair) or when the fracture is open (for irrigation and debridement to prevent infection). Open reduction may be done without using hardware when closed reduction is ineffective.

Fractures, whether they require reduction, surgery, or neither, are typically immobilized, as are the proximal and distal joints. Usually, a cast is applied for weeks or months, but a splint may be used instead, particularly for fractures that heal faster when mobilized early. Home care for fractures includes supportive measures such as RICE (rest, ice, compression, elevation—see Fractures, Dislocations, and Sprains: RICE).

Patients are told to seek care immediately if symptoms of compartment syndrome occur (see Fractures, Dislocations, and Sprains: Compartment Syndrome).

Geriatric Essentials

The elderly are predisposed to fractures because of osteoporosis, a tendency to fall frequently, drug side effects, and impaired protective reflexes during falls. Age-related fractures tend to affect the metaphysis (the flared area between the end and shaft). They include fractures of the distal radius, proximal humerus, proximal tibia, proximal femur, pubic ramus, and vertebrae.

The goal of treatment is rapid return to activities of daily living rather than restoration of perfect limb alignment and length. Because immobilization (joint immobilization or bed rest) is more likely to cause adverse effects in the elderly, use of ORIF is increasing. Early mobilization and physical therapy are essential to recovery of function. Coexisting disorders (eg, arthritis) can interfere with recovery.

Specific Fractures

Stress fractures: Stress fractures are small and result from repetitive force (eg, from overuse); they occur most often in the metatarsals (usually in runners—see Exercise and Sports Injury: Metatarsal Stress Fracture), followed by the fibula and tibia. Symptoms include gradual onset of intermittent pain that worsens with weight bearing and eventually becomes constant. Sometimes swelling occurs.

Examination detects localized bone tenderness. Plain x-rays are done but may not show the fracture at first. Thus, many such fractures are treated presumptively, and plain x-ray is repeated 2 to 3 wk later when callus may be visible. Treatment is rest, elevation, analgesics, and sometimes immobilization. CT or MRI is rarely needed.
v Growth plate fractures: Bone grows as tissue is added proximally by the epiphyseal disk (growth plate), which is bordered by the metaphysis proximally and the epiphysis distally (see Fig. 4: Fractures, Dislocations, and Sprains: Epiphyseal disks (growth plates).Figures ). The age at which the growth plate closes and bone growth stops varies by bone, but the growth plate is closed in all bones by the end of puberty. If there is question about a growth plate injury or if a fracture is suspected, opposite side comparison x-rays may be helpful.

Fig. 4 Epiphyseal disks (growth plates).
Epiphyseal disks (growth plates).
The growth plate is the most fragile part of the bone and thus is usually the first structure disrupted when force is applied. Growth plate fractures are classified by the Salter-Harris system (see Fig. 5: Fractures, Dislocations, and Sprains: Salter-Harris classification of epiphyseal disk (growth plate) fractures.Figures ). Disruption of future bone growth is common with types III, IV, and V but uncommon with types I and II.

Fig. 5

Salter-Harris classification of epiphyseal disk (growth plate) fractures.
Salter-Harris classification of epiphyseal disk (growth plate) fractures.

Types I through IV are physeal fractures; the growth plate is separated from the metaphysis. Type II is the most common, and type V is the least common.

Growth plate fractures are suspected in children with tenderness localized over the growth plate. These fractures cause circumferential tenderness and thus can be clinically differentiated from contusions. In fracture types I and V, x-rays may appear normal. If so, these fractures can sometimes be differentiated from each other by injury mechanism—eg, distraction (separation in longitudinal axis) vs compression.

Closed treatment is usually sufficient for types I and II; ORIF is often required for types III and IV. Patients with type V injuries should be referred to a pediatric orthopedist because such injuries almost always lead to growth abnormalities.

Rib fractures: Typically, rib fractures result from blunt injury to the chest wall, usually involving a strong force (eg, from high-speed deceleration, a baseball bat, a major fall); however, sometimes in the elderly, only mild or moderate force (eg, in a minor fall) is required. Concomitant injuries may include *

Aortic, subclavian, or cardiac injuries (uncommon but can occur with high-speed deceleration, particularly if rib 1 or 2 is fractured) *
Splenic or abdominal injuries (with fractures of any of ribs 7 through 12)
* Pulmonary laceration or contusion
* Pneumothorax
* Other tracheobronchial injuries (uncommon)

Pain is severe, is aggravated by movement of the trunk (including coughing or deep breathing), and lasts for several weeks. Inspiratory splinting (incomplete inspiration due to pain) can cause atelectasis and pneumonia, especially in the elderly or those with multiple fractures. Young healthy patients and those with 1 or 2 rib fractures rarely develop these complications.

Palpation of the chest wall may identify some fractures, and sometimes the patient and the examining clinician can feel the broken ribs move when the lungs are expanded. A chest x-ray is taken routinely to check for concomitant injuries (eg, pneumothorax, pulmonary contusion). Many rib fractures are not visible on a chest x-ray; specific rib views may be needed, but identifying all rib fractures by x-rays is not always necessary. Other tests are done to check for concomitant injuries that are clinically suspected.

Treatment requires opioid analgesics, which can depress respiration and worsen atelectasis. To minimize pulmonary complications, patients should consciously and frequently (eg, hourly) breathe deeply or cough while awake. Holding (essentially splinting) the affected area with the flat palm of the hand or a pillow can help minimize the pain during deep breathing or coughing. Patients are hospitalized if they have ≥ 3 fractures or underlying cardiopulmonary insufficiency. Immobilization (eg, by strapping or taping) should usually be avoided; it constricts respiration and may predispose to atelectasis and pneumonia.

Clavicle fractures: The usual injury mechanism is a fall on an outstretched arm or a direct blow. About 80% involve the middle 1⁄3 of the bone and are immobilized with a sling. Previously used figure-of-eight braces are no more helpful (and are more uncomfortable) than a simple sling. Reduction is not necessary even for greatly angulated fractures. Clavicle fractures that significantly tent the skin or that involve areas other than the middle 1⁄3 of the bone may require additional intervention.

Proximal humeral fractures: The usual injury mechanism is direct force or a fall on an outstretched arm. Usually, displacement and angulation are minimal. Contractures may develop after only a few days of immobilization, particularly in the elderly. Minimally displaced or angulated fractures are treated with immobilization in a sling and swathe (see Fig. 1: Fractures, Dislocations, and Sprains: Joint immobilization as acute treatment: some commonly used techniques.Figures) and early range-of-motion exercises. More severe fracture may require ORIF or surgery to insert a prosthetic joint (shoulder replacement).

Distal humeral fractures: The usual injury mechanism is direct force or a fall on an outstretched arm. The brachial artery or radial nerve may be damaged. Angulation, if present, must be corrected. Casting with closed reduction may be tried, but ORIF may be necessary.

Radial head fractures: The usual injury mechanism is a fall on an outstretched arm. The radial head is palpated on the lateral elbow as a structure that rotates during pronation and supination. Routine anteroposterior and lateral x-rays usually show a joint effusion or a displaced anterior fat pad (sail sign) but often do not show the fracture. Patients with localized radial head tenderness and effusion require oblique views (which are more sensitive for fracture) or presumptive treatment of a fracture. For fractures with only minimal angulation and displacement, treatment is a splint with the elbow flexed 90° or a sling. Arthrocentesis to remove blood from the joint often helps relieve pain and facilitate recovery. Starting range-of-motion exercises 10 days after the injury maximizes joint flexibility.

Distal radial fractures: The usual injury mechanism is wrist hyperextension, usually during a fall. Dorsally displaced or angulated fractures (sometimes called Colles' fractures) are common. Treatment is reduction and immobilization at 15 to 30° of wrist extension. ORIF may be necessary if the joint is disrupted or if there is excessive impaction or shortening.

Metacarpal neck fractures (except thumb): The usual injury mechanism is an axial load (eg, from punching with a clenched fist). If wounds are near the metacarpophalangeal joint, contamination with human oral flora should be considered, and measures to prevent infection are often required (see Bites and Stings: Antimicrobials). Reduction is necessary for fractures of the 2nd and 3rd metacarpals but is unnecessary for dorsal or volar angulation of < 35° for the 4th metacarpal or of 45° for the 5th metacarpal. Treatment is a splint (eg, an ulnar gutter splint for fractures of the 4th or 5th metacarpal—see Fig. 1: Fractures, Dislocations, and Sprains: Joint immobilization as acute treatment: some commonly used techniques.Figures).

Scaphoid (navicular) fractures: The usual injury mechanism is wrist hyperextension, usually during a fall on the outstretched hand. Avascular necrosis is a common complication, even when initial care is ideal, and can cause disabling, degenerative arthritis of the wrist. Fracture signs include pain with axial compression of the thumb, pain with wrist supination against resistance, and, particularly, tenderness in the anatomic snuffbox with ulnar wrist deviation. The anatomic snuffbox is palpated just distal to the radius between the extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus tendons. The initial plain x-ray is often normal. If a fracture is still suspected, MRI, which is more sensitive than x-rays, is done, or fracture is presumed and treated with a thumb spica splint, with a follow-up plain x-ray taken in 1 to 2 wk. Rarely, this subsequent x-ray is falsely normal.

Fingertip (tuft of the distal phalanx) fractures: The usual mechanism is a crush injury. Subungual (beneath the nail) hematoma usually occurs and produces a blue-black, tender bruise, which may elevate the nail; hematoma indicates a nail bed laceration. Most fingertip fractures are treated symptomatically with a protective covering (eg, commercially available aluminum and foam splint material) wrapped around the fingertip. Subungual hematomas can be drained to relieve pain by puncturing the nail (trephination), usually with an 18-gauge needle in a rotatory motion or, if no nail polish is on the nail, with an electrocautery device. If trephination is done gently and rapidly, anesthesia is often unnecessary. Large displaced fractures are rarely repaired surgically. Markedly disrupted nail beds are repaired with sutures but are best left alone if the nail is closely adherent to the nail bed. Hyperesthesia frequently persists long after a large fracture has healed and requires desensitization therapy.

Pelvic fractures: Pelvic fractures may be stable or unstable. Compression of the pubic symphysis or simultaneous compression of both anterior superior iliac spines is often painful, particularly in severe fractures. For pelvic fractures, CT is more sensitive than plain x-rays.

Stable fractures do not disrupt the pelvic ring. Some (eg, symphyseal or pubic ramus fractures) result from minor injuries (eg, falls at home), especially in patients with osteoporosis. Treatment is often symptomatic, particularly if patients can walk unaided.

Unstable fractures disrupt the pelvic ring in ≥ 2 places; disruptions can be fractures within bones or separations between the fibrous joints (syndesmoses) between bones. Unstable fractures usually result from substantial forces (eg, high-speed motor vehicle collisions). Intestinal injuries may occur. Concomitant GU injuries (eg, urethral or bladder tears) are common, particularly with anterior pelvic fractures. Vascular injuries may occur and cause hemorrhagic shock, especially with posterior pelvic fractures. Mortality rate is high. Initial evaluation and treatment are directed at associated injuries. The fracture often requires surgical repair.

Hip fractures: Hip fractures are most common among the elderly, particularly those with osteoporosis (mostly women—see Osteoporosis). Most fractures result from falls, but in the elderly, seemingly minimal force (eg, rolling over in bed, getting up from a chair, walking) can result in hip fracture, usually because osteoporosis has weakened bone. Subcapital femoral neck and intertrochanteric fractures are the most common types. Hip fractures often cause referred pain in the knee and thus may be misinterpreted as a knee abnormality. Pubic ramus fractures can produce hip pain.

Subcapital fractures may result from a single injury but often result from repeated stress or minimal force, resulting in a small or large stress fracture. A fall after the initial fracture may worsen or displace the fracture. Patients with small fractures may be ambulatory and have only mild pain. However, such patients may be unable to flex the entire lower limb against resistance with the knee extended. Passive hip rotation with the knee flexed aggravates the pain, helping to differentiate hip fracture from extra-articular disorders such as trochanteric bursitis. Large or displaced fractures tend to limit hip motion more, shorten the leg, and cause the leg to rotate externally. Displacement predisposes to osteonecrosis of the femoral head and fracture nonunion.

Plain x-rays are occasionally normal when fractures are small or impacted or when osteoporosis is severe. If a fracture is still suspected, MRI is done; if MRI is unavailable or contraindicated, CT is done. If patients are expected to resume walking and have no contraindication to surgery, treatment is usually surgical repair (typically ORIF—see Fig. 6: Fractures, Dislocations, and Sprains: Open reduction with internal fixation (ORIF).Figures) and early ambulation.

Fig. 6
Open reduction with internal fixation (ORIF).
Open reduction with internal fixation (ORIF).

If patients are elderly, are not active, and have displaced fractures, treatment is often prosthetic replacement of the femoral head, typically with a Moore prosthesis, or total hip replacement. Occasionally, the femoral head must be replaced when the fracture is displaced in younger adults, particularly those who are inactive. Usually, prolonged bed rest should be avoided in elderly patients. Bed rest increases the risk of deep venous thrombosis, a common complication of hip fractures. Prophylactic anticoagulation may reduce the incidence of post−hip fracture venous thrombosis.

Intertrochanteric fractures usually result from falls or direct blows. Patients have tenderness, ecchymosis, and swelling over the hip; usually, the leg is shortened and rotates externally. Plain x-rays are usually diagnostic. Treatment is usually ORIF and early mobilization.

Femoral shaft fractures: The usual injury mechanism is severe direct force or an axial load to the flexed knee. Fracture due to trauma causes obvious swelling, deformity, and instability. Up to 1.5 L of blood for each fracture may be lost. Treatment is immediate splinting, then ORIF.

Ankle fractures: The ankle bones and ligaments form a ring that connects the tibia and fibula to the talus and calcaneus. Within the ring, stability is provided by 2 bones (the medial malleolus of the tibia and lateral malleolus of the fibula) and 2 ligament complexes (medially, the deltoid ligament; laterally, mainly the anterior and posterior talofibular ligaments and calcaneofibular ligament—see Fig. 7: Fractures, Dislocations, and Sprains: Ligaments of the ankle.Figures ). Ankle fractures are common and can result from multiple injury mechanisms. Fractures that disrupt the ring in one place often disrupt it in another (eg, if only one bone is fractured, a ligament is often simultaneously and severely torn). If fractures disrupt ≥ 2 of the structures stabilizing the ankle ring, the ankle is unstable. Disruption of the medial deltoid ligament also causes instability. For unstable injuries, surgery may be required, and prognosis is guarded. Most stable ankle fractures without other indications for surgery can be treated with a cast for 6 wk; prognosis is good.

Fractures of the 2nd metatarsal bone base with dislocation (Lisfranc's fracture-dislocation): The usual mechanism is a fall on a foot in plantar flexion. Usually there is significant soft-tissue swelling. These rare fractures are difficult to appreciate on plain x-rays and are often misdiagnosed, leading to sometimes serious complications, such as osteoarthritis and rarely compartment syndrome. A plain x-ray can show a fracture at the base of the 2nd metatarsal or chip fractures of the cuneiform but may not show disruption of the tarsometatarsal joint, which should be suspected even if it is not visible on plain x-rays. Dislocations often spontaneously reduce, but immediate referral, usually for closed reduction, which requires general anesthesia, may be warranted.

Fractures of the 5th metatarsal bone base (dancer's fracture): The usual injury mechanism is a twist (typically, inversion) or crush injury. These fractures usually heal relatively quickly; nonunion is uncommon. Treatment is a protective walking shoe.

Fractures of the 5th metatarsal bone diaphysis (Jones fracture): The usual injury mechanism is a crush injury. These fractures are less common than those of the metatarsal bone base, and delayed union or nonunion occurs more commonly. Treatment is a cast that immobilizes the ankle. Avulsion fractures of the base of the fifth metatarsal can occur with inversion ankle injuries and are less significant than a true Jones fracture, the latter being predisposed to nonunion.

Toe fractures: The usual injury mechanism is a crush injury. Unless rotational deformity or joint involvement is suspected or the proximal phalanx of the great toe is injured, x-rays are usually unnecessary. Treatment is taping the injured toe to an adjacent toe (dynamic splinting or buddy taping). Markedly displaced toe fractures should be reduced to restore alignment.

How long does it take a fracture to heal?
It can take anywhere from a few weeks to several months for a fracture to heal. Everyone's body is different and your body may take more or less time to heal.

How are fractures treated?
Commonly, a plaster or fiberglass cast stabilizes the broken bone while it is healing. For some fractures, doctors use functional casts, which are made from material that allows some controlled movement. Severe fractures may require surgery. During surgery, doctors may insert screws to hold the bones in place or attach plates to the outer surface of the bones.

The method of treatment depends on a variety of factors, including the type and location of the fracture and its severity.

Treatments may include:
Brace, cast, splint or sling
Use of crutches, walker or cane

Doctors use casts, splints, pins, or other devices to hold a fracture in the correct position while the bone is healing.

External fixation methods include plaster and fiberglass casts, cast-braces, splints, and other devices.

Internal fixation methods hold the broken pieces of bone in proper position with metal plates, pins, or screws while the bone is healing.

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury.

Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint.
Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the doctor believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remain empty for potential anesthesia.

A decision will be made whether x-rays are required, and which type of x-ray should be taken to make the diagnosis and better assess the injury. There are guidelines in place to help doctors decide if an x-ray is necessary.


Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk (for staying where it is) once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery.

Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time.

The most common types of internal fixation are wires, plates, rods, pins, nails, and screws used inside the body to support the bone directly.


Wires are often used as sutures or threads to "sew" the bones back together.

* Can be used in conjunction with other forms of internal fixation to hold bones together.
* Can be used alone to treat fractures of small bones, such as those found in the hand or foot.


* Pins hold pieces of bone together. They are usually used in pieces of bone that are too small to be fixed with screws.
* These pins are usually removed after a certain amount of time, but may be left in permanently for some fractures.


Plates are like internal splints that hold the fractured ends of bone together.

* Extend along the bone and are screwed in place. If two bones that run parallel to each other both break, such as in the lower leg, plating one bone may provide enough support for the other bone as well.

* May be left in place or removed (in selected cases) after healing is complete.

Nails or Rods

In some fractures of the long bones, the best way to align the bone ends is by inserting a rod or nail through the hollow center of the bone that normally contains some marrow.

* Held in place by screws until the fracture has healed.
* May be left in the bone after healing is complete.


Bone screws are used for internal fixation more often than any other type of implant. Although the bone screw is a simple device, there are several designs based on how the screw will be used.

* Can be used alone to hold a fracture, as well as with plates, rods, or nails.
* May be designed for a specific type of fracture.
* May be left in place, or removed after the bone heals.

External Fixators

Pins, screws, and rods are also used to construct external fixators, such as frames and rings. Although they are outside the body, the screws and pins go through the skin and muscle to connect to the bone. In this way, they differ from casts and splints, which rely solely on external support. There may be some inflammation or, less commonly, infection associated with the use of external fixators. Normally, these can be managed with wound care and/or oral antibiotics.

For Patients

How long do I have to use my crutches/walker/cane?
When can I put more weight on my leg?
How long do I have to use the brace/splint?
Can I shower?
When can I go back to work/school?
When can I drive?
What happens to the metal pins, screws, and plates?
Will they set off a metal detector?
Will they stay in my body permanently or will they be removed?
Should I put ice or heat on any of my swollen areas? If so, for how long?
How long until I can go back to the gym or play sports again?
When may I resume sexual activity?
How long will I be in the hospital?
When should I see my doctor again?
Do I need x-rays for my next office visit?
When do my sutures/staples come out?
Should I take them out myself, see my local doctor or return to my surgeon?
How often do I need to change my dressing?
How long will I need to take medication?
How will the staff of the rehabilitation hospital or home care agency know what my injuries are and what my orthopaedic surgeon's plan is?
Will my surgeon still manage my care during my rehabilitation?

How long do I have to use my crutches/walker/cane?
Your doctor will determine when it is safe for you to bear weight on your injured leg and stop using your crutches. Many fractures require no weight bearing until they are fully healed. Using the crutches/walker/cane for a shorter period of time than your doctor tells you may cause complications.

When can I put more weight on my leg?
Your weight bearing status will be explained to you before you are discharged from the hospital. If you are able to bear weight as tolerated, you can put more weight on your leg as it feels comfortable to do so. If you are considered non- or partial-weight bearing, your surgeon will evaluate you at your next appointment to determine whether it has become safe for you to bear more weight.

How long do I have to use the brace/splint?
Your doctor and therapist will instruct you on when and for how long you will need to use your brace or splint.

Can I shower?
It depends on your injury. You should not shower if you have any open wound or drainage coming from your incision (surgery) site. If your wound is closed, there is no drainage and you feel that it is safe for you to shower, you can cover the incision with a plastic wrap (i.e., Saran Wrap) and shower safely. If the incision gets wet, pat it dry. If you have a cast, it must be covered with a shower bag or plastic bag to keep it dry. If the cast gets wet, it must be changed.

When can I go back to work/school?
We recommend that you wait until your first outpatient appointment with your surgeon to see how you are healing. During this first follow-up appointment, you should discuss the nature of your work and/or school with your surgeon.

When can I drive?
This is not an easy question to answer because it involves more than your doctor’s medical clearance, which is based on your safety and healing progress. You should also consider the policies of the Registry of Motor Vehicles and your insurance company. For example, if you are involved in an accident and you are wearing a leg brace or have crutches in the car, it may appear that you have limited abilities and could be blamed for what happened. Once your doctor gives you medical clearance, you will need to decide if you feel able and well enough to drive.

What happens to the metal pins, screws, and plates?
Will they set off a metal detector?
Will they stay in my body permanently or will they be removed?
Depending on your fracture, the metal may stay in your body until you have healed or until it is no longer necessary. Some fractures require that the metal remain permanently. Your surgeon will let you know. As for the metal detectors, they should not be sensitive enough to detect the metal. If they are, you should explain to the security personnel that you have had surgery requiring metal fixation.

Should I put ice or heat on any of my swollen areas? If so, for how long?
You may apply ice to the area to decrease swelling and relieve pain for 10 to 15 minutes per hour as needed. You should not apply heat, as it will increase your swelling.

How long until I can go back to the gym or play sports again?
The answer to this question is almost the same as returning to work or school. You can discuss this question with your surgeon during your first office visit.

When may I resume sexual activity?
The answer to this question varies according to the injuries you have sustained. Your doctor or occupational therapist can give you information to help you decide when and how you can safely resume sexual activity.

How long will I be in the hospital?
Trauma patients, on average, stay in the hospital for four to five days. You may be discharged before or after this time depending on the nature of your injuries and/or your health insurance coverage.

When should I see my doctor again?
Before you are discharged from the hospital, you will be given specific instructions about where and when you should see your doctor.

Do I need x-rays for my next office visit?
If you had surgery to repair a fractured bone, each of your regularly scheduled follow-up appointments will require an x-ray of the bone.

When do my sutures/staples come out?Should I take them out myself, see my local doctor or return to my surgeon?
Sutures and staples are removed by a doctor or nurse within two to three weeks of surgery. If the staples/sutures have not been removed while you were in the hospital or rehabilitation hospital, you should call your doctor for an appointment. You should not attempt to remove these yourself.

How often do I need to change my dressing?
The answer to this question depends on the type of wound or incision that you have. The team will discuss this issue with you before you leave the hospital, and your nurse will show you how to do dressing changes at home. Sometimes, the visiting nurse can assist with dressing changes at home or provide instructions to you and/or your family.

What do I do with all of my insurance and disability forms?
We will complete any insurance, disability or transportation forms for you. Please send these forms to your surgeon’s office with the patient sections completed and signed.

Can I apply for a handicap placard or license plate?
Yes, you may contact the Registry of Motor Vehicles in your state to request a disabled placard/plate form. Complete the patient information section of this form and send it to your surgeon so that he/she may complete the appropriate section. The registry may require you to retake a driver’s test or outfit your car with appropriate modifying equipment before they grant such a placard or plate.

How long will I need to take medication?
The answer to this question depends on the type of medication(s) you have been prescribed. If you are on blood thinning medicine like aspirin, coumadin or Lovenox , or antibiotics for infection, you will need to take it as long as the doctor feels it is necessary. Pain medications should be taken only when needed, as it is expected that the pain will steadily lessen as the fracture heals. [Please see previous section on pain — in Common Issues after Trauma.]

How will the staff of the rehabilitation hospital or home care agency know what my injuries are and what my orthopaedic surgeon’s plan is?
Before you leave the hospital, the team will write a referral to the next “team” from the rehabilitation hospital or agency who will help you continue your recovery. The referral is a document that includes your relevant medical history, your medications, your therapy plan and any restrictions you may have to keep you safe — such as reduced weight-bearing on a leg.

Will my surgeon still manage my care during my rehabilitation?
If you go to a rehabilitation hospital, you will have a new physician from the rehabilitation hospital who will oversee the plan your BWH surgeon has set up. The staff of the rehabilitation hospital will contact your BWH surgeon should any issues arise. Patients who go to the Spaulding Rehabilitation Hospital are visited by an attending physician from our team once a week to monitor their progress and healing in conjunction with the Spaulding team.


You can reduce your chances of getting a fracture by:
Not putting yourself at risk for an accident or other trauma to the bone
Not putting yourself at risk for any sabotage
Can a fracture be induced? How?
Eating a diet rich in calcium and vitamin D
Regularly doing weight-bearing exercise to build and maintain strong bones
Regularly doing strengthening exercises to build strong muscles and prevent falls
Patients with osteoporosis may benefit from bisphosphonate medications

Will surgery be required for the external fixation?
What type of anesthesia will be used?
How is the surgery performed?
What can be expected after the surgery?
How long is the hospital stay?
How long will the pins and steel rods be required?
How will the pins and steel rods be removed?

With external fixation, pins are inserted through the skin into the bone and held in place by an external frame.

The usual indications are open fractures such as a tibia fracture which requires dressings or attention to a wound or flap.

It can also be used with closed fractures e.g. unstable radius fracture.

External fixation is most successful in superficial bones e.g. tibial shaft. Avoid it in deeper bones e.g. the femur or humerus - here the chance of pin tract sepsis is greater.

Ilizarov Exfix for high tibial fracture Ilizarov external fixator on a tibia. This type of fixator, although somewhat tiresome to assemble, has a low incidence of pin-site sepsis, is very stable, and is ideal in a metaphyseal region. It is often used for bone lengthening as well as bone transport procedures Tibial fracture fixed with an Ilizarov frame

Advantages of external fixation

1. The method provides rigid fixation of the bones in cases in which other forms of immobilization, for one reason or another, are inappropriate. This is most common in severe, open types II and III fractures in which cast or traction methods would not permit access for management of the soft tissue wounds and in which exposure and dissection to implant an internal fixation appliance would devitalize and contaminate larger areas and might significantly increase the risk of infection or loss of the limb itself.
2. Compression, neutralization, or fixed distraction of the fracture fragments is possible with external fixation, as dictated by the fracture configuration. Uncomminuted transverse fractures can be optimally compressed, length can be maintained in comminuted fractures by pins in the major proximal and distal fragments (neutralization mode), or fixed distraction can be obtained in fractures with bone loss in one of paired bones, such as the radius or ulna, or in leg-lengthening procedures.
3. The method allows direct surveillance of the limb and wound status, including wound healing, neurovascular status, viability of skin flaps, and tense muscle compartments.
4. Associated treatment, for example, dressing changes, skin grafting, bone grafting, and irrigation, is possible without disturbing the fracture alignment or fixation. Rigid external fixation allows aggressive and simultaneous treatment of bone and soft tissues.
5. Immediate motion of the proximal and distal joints is allowed. This aids in reduction of edema and nutrition of articular surfaces and retards capsular fibrosis, joint stiffening, muscle atrophy, and osteoporosis.
6. The extremity is elevated without pressure on the posterior soft tissues. The pins and frames can be suspended by ropes from overhead frames on the bed, aiding edema resolution and relieving pressure on the posterior soft tissue part.
7. Early patient mobilization is allowed. With rigid fixation the limb can be moved and positioned without
8. fear of loss of fracture position. In stable, uncomminuted fractures early ambulation is usually possible; this may not be the case if these fractures are treated by traction or casting. Use of external fixation also allows mobilization of some patients with pelvic fractures. Insertion can be performed with the patient under local anesthesia, if necessary. If a patient’s general medical condition is such that use of a spinal or general anesthetic is contraindicated, the fixator can be inserted using local anesthesia, although this is not optimal.
9. Rigid fixation can be used in infected, acute fractures or non union's. Rigid fixation of the bone fragments in infected fractures or in infected established non union's is a critical factor in controlling and obliterating the infection. This is rarely possible with casting or traction methods, and implantation of internal fixation devices is often ill advised. Modern external fixators in such instances can provide rigidity not afforded by other methods.
10. Rigid fixation of failed, infected arthroplasties in which joint reconstruction is not possible and in which arthrodesis is desired can be achieved. Disadvantages of external fixation 1. Meticulous pin insertion technique and skin and pin tract care are required to prevent pin tract infection. 2. The pin and fixator frame can be mechanically difficult to assemble by the uninitiated surgeon. 3. The equipment is expensive. 4. The frame can be cumbersome, and the patient may reject it for aesthetic reasons. 5. Fracture through pin tracts may occur. 6. It is difficult to do delicate surgery such as skin flaps once the exfix apparatus is in place. Rather do this type of surgery before the frame is applied. 7. Re fracture after exfix removal may occur unless the limb is adequately protected (e.g. by walking cast application), until the underlying 8. bone can again become accustomed to stress. The noncompliant patient may disturb the appliance adjustments. 9. The head injured patient may injure himself by thrashing his pin studded limb against other parts. 10. Joint stiffness may occur if the fracture requires that the fixator immobilize the adjacent joint. e.g. an exfix placed over the ankle for a pilon fracture as there was insufficient space for pins in the distal tibial fragment.


There are many potential complications with sepsis being the most common.

Pin tract infection. Without proper technique for pin insertion and meticulous pin tract care, this may be the most common complication, occurring in 30% of patients. It varies from minor inflammation remedied by local wound care, to superficial infection requiring antibiotics, local wound care, and occasional pin removal, to osteomyelitis requiring sequestrectomy. A "ring sequestrum" is the radiological appearance of a sclerotic ring about the hole left from a transfixion pin (from an exfix or other skeletal traction device.

Neurovascular impalement. Know the anatomy of the underlying limb, and avoid major neurovascular structures. The surgeon must be familiar with the cross-sectional anatomy of the limb and with the relatively safe zones and danger zones for pin insertion The radial nerve in the distal half of the arm and proximal half of the forearm, the dorsal sensory radial nerve just above the wrist, and the anterior tibial artery and deep peroneal nerve at the junction of the third and fourth quarters of the leg are the structures most often involved. Vessel penetration, thrombosis, late erosion, arteriovenous fistulas, and the formation of aneurysms have also been observed. Muscle or tendon impalement. Pins inserted through tendons or muscle bellies restrain the muscle from its normal excursion and can lead to tendon rupture, or muscle fibrosis. Ankle stiffness is frequent if multiple transfixing pins are used in fractures of the tibia.

Delayed union. The rigid pins and frames can ‘‘unload’’ the fracture site, with cancellization and weakening of the cortex similar to that noted with internal rigid compression plate fixation if the fixator remains in place for several weeks or months. The callus produced is entirely endosteal, and delayed unions in 20% to 30% (and as many as 80%) of fractures have been reported in the literature with prolonged use of the rigid fixator.

Compartment syndrome May occur in the limb treated with an external fixator. Unlike open surgery which opens facial planes, an external fixator is basically a closed method and there is a higher rate of compartmental syndrome.

Refracture. Union due to the rigid fixation is largely endosteal, with very little peripheral callus formation. The de stressing of the cortical bone by the rigid fixation results in cancellization of the cortex; refracture is possible after fixator removal unless the limb is adequately protected by crutches, supplemental casts, or supports.

Limitation of future alternatives. Such methods as open reduction become difficult or impossible if pin tracts become infected. If an external fixator is left in more than a week, there is a higher rate of infection if open reduction and internal fixation (ORIF) is later attempted. Do not use an exfix for an extended period ,if you anticipate open reduction will later be required. It is safe to do ORIF, however if the exfix removed within a week of application. In "Damage Control" surgery i.e. where anaesthetic time must be limited due to other life threatening conditions, in the multiply injured, a temporary exfix is a solution. Later when the patients condition stabilises, the exfix can be replaced by performing definitive open reduction and internal fixation.

How not to place an exfix pin: The pin is too near the fracture and the skin is tented

Avoid causing osteomyelitis

Place pins away from fracture lines. Organisms may gain access and infect the bone about the fracture area.

Skin "tenting" i.e. folds caused by skin compression against the pin must not be tolerated - these folds lead to pin tract sepsis. Make a relaxing incision on the side of the fold, and suture any resulting wound.

Causes of pin sepsis

Site selection

The more soft tissue there is, the greater is the chance for sepsis. Site the pin where the bone is as superficial as possible.

Skin tethering

Place the pin so as not to tension the skin. Close wounds, if possible before inserting the pin, as closure will be likely to move the skin. Make relaxing incisions to relieve skin tension - suture the resulting defect if necessary.

Use of power instruments

Drilling wide diameter pins directly into bone will generate heat, this may lead to sequestrum formation and sepsis. Either pre drill the pins with a helical drill, or use hand instruments to insert the pin.

Pin Care

Inadequate pin care and poor hygiene may lead to sepsis

Pin Care

1. Clean the skin / pin interface of all discharges twice daily
2. Antiseptic dressings - "Betadine" (povidone) ointment
3. Inflamed or septic skin about a pin (not loose) - Appropriate (oral) antibiotic
4. Septic Loose Pin - remove, and replace with another through normal skin

1. Simple outpatient procedure
2. Remove the exfix once its job is done. Replace the device with POP cast once skin defect ( the reason the exfix was put on for) has healed, and fracture has stabilised enough not to easily displace.

Open Reduction

* Indications for Open reduction and internal fixation - Tibial Shaft Inability to obtain a reduction * Inability to maintain a reduction * Vascular complications

Intramedullary pin for unstable tibia fracture

IM Pin

Recently there has been a swing towards intramedullary pinning of the tibia. The procedure has a low sepsis rate and pin breakages are rare. Any closed unstable fracture of the shaft (large butterfly segment or comminution) can be considered candidate for this method. It is difficult to successfully plate a tibia shaft as there is a high rate of sepsis due to its poor distal blood supply, and the proximity of the skin to the bone lets in sepsis.

Tibial fractures are often open due to most of the anterior border of the shaft being subcutaneous. The wound must be inspected in the trauma ward and then covered with a sterile dressing. A broad spectrum antibiotic is given (first generation cephalosporin plus amiloglycocide if very contaminated) Prophylaxis against tetanus is also necessary. Curetting tibial marrow cavity during debridement Curetting out the medullary cavity. The bone may have become contaminated when it embedded in the ground

In theater the leg is scrubbed before it is draped. The wound is incised to a larger size if it is too small for access. All dead tissue is excised. Viable muscle will bleed, and should contract if pinched with a forceps - if it does not it needs excision. Preserve nerve tissue and suture if transected. Vessels may need repair at his stage. Lose pieces of bone ( no muscle attachments) are discarded. Leave the wound open for secondary suture later. take tissue and pus swabs for areobic and anaerobic culture) The wound needs irrigation with copious water (10 litres or more). A pulsed lavage system is invaluable in getting fine contaminants out of the tissue. If there is a large soft (Gustillo 3b type or more ) tissue defect consult a plastic surgeon regarding a primary flap to close the defect. The limb is stablised - use an exfix if the wound is large or will need attention later (skin graft etc.) If the wound is small and easily closable a paster cast may be necessary. Open reduction is not recommended at this primary debridement. It may be done at a later stage (48 hr.+) in the less contaminated fracture (below Gustillo 3B).

A second debridement at 48 hours is recommended in all contaminated cases. Here further non viable tissue is identified and removed. Wounds may be sutured at this stage if the wounds appear clean.

Delayed and Non Union

The tibia should begin to show signs of callus formation on X rays from six weeks onwards. The fracture becomes less mobile when stressed and the pain diminishes. If the tibia does not show signs of union or does not progress as expected delayed union may be diagnosed. Make sure there are not causes such as sepsis, medical conditions such as diabetes etc. Smoking inhibits fracture union and should be discouraged. Non union has occurred when there is no progress towards union and the fracture is pain free. Established non union, the intact fibula has hypertrophied over time Established nonunion. This man had fractured his tibia 20 years previously. He only had minimal pain. Note the hypertrophy of the fibula.

Treatment of delayed union needs to address the cause. Conservative treatment such as a dynamic cast (patellar tendon bearing cast) may stimulate union. If this fails, surgical measures are necessary. If sepsis is the cause a sequestrectomy of the fracture area is needed. If there is abundant callus but none bridges the gap (hypertrophic delayed union -"Elephant's foot" type) more stability is called for. An open reduction and internal fixation may be needed. The two types of delayed union: Hypertrophic (mechanical cause) and Hypotrophic (avascular)Hypotrophic delayed unions ( where there is little callus) are due to vascular reasons (e.g.severe stripping of soft tissue in an open fracture) Here a bone graft as well as further stabilisation (ORIF or Exfix) will be needed. Mal alignment is a potent cause of non or delayed union, as there are shear and angulatory forces tearing apart all attempts by capillaries to bridge the fracture gap. In this case a realignment procedure with fixation by exfix, or intramedullary pin is called for.

What is a broken bone (fracture)?
What causes a broken bone?
What are the most common types of broken bones?
What are the most common bones that are broken?

What are the most common bones that are broken?
The most common fractures involve the clavicle (collarbone), the forearm (radius and ulna), the wrist, the ankle and the hip. Closed fractures are more common than open fractures (the skin overlying the injury is intact and not damaged).

In children, a fracture of the distal radius is most common. The break occurs in the radius near the wrist but usually does not involve the joint itself.

Broken hand or fingers
Bones of the Hand and Wrist
Illustration of Hand and Wrist Bones

Injuries to the hands and fingers are very common because they are exposed in daily activities. In addition to the bones, the health care professional will be interested in making certain there are no tendon or nerve injuries associated with any broken bone(s). Because the anatomy of the hand is so complex, complicated fractures may be referred to an orthopedic or plastic hand specialist. Many of them will only require splinting or casting, but occasionally surgery will be necessary.

Broken wrist

Falling on an outstretched hand is the most common reason for a wrist fracture. It is often the distal radius (see illustration) that is damaged, and the fracture may involve more than one bone. Aside from the radius, wrist fractures may also include fractures of the carpal bones of the wrist (carpus), those that connect the radius to the long bones of the hand (metacarpals). Doctors often look for fractures of the scaphoid bone (the bone between the bottom of the thumb and the top of the radius), and dislocations of the lunate (the bone next to the scaphoid bone) that may be difficult to see on plain X-ray.

In some cases, the wrist is splinted even if X-rays are normal because upon physical examination the doctor may be concerned about a potential occult or hidden fracture (the fracture is so small that it does not show up on an X-ray).

Depending upon the bone that is injured and it's alignment, surgery may or may not be required. Regardless of the treatment, the goal is to have a normally aligned wrist, especially if the fracture involves the joint surface. Poor alignment may lead to arthritis in the future.

Broken hip

Hip fractures are perhaps the most common fracture seen in people 75 years of age or older. While falls and trauma may be the obvious cause, many times, people are more susceptible to hip fracture because of osteoporosis and sometimes the hip will break spontaneously.

The hip joint is made up of the interconnection of two bones in a ball and socket: 1) the socket in the pelvis (acetabulum), and 2) the ball (femoral head). Hip fractures refer to the femur fracture.

Almost all hip fractures require surgery and the type of surgery depends upon where in the femur that the fracture is located.

Broken leg

Picture of the bones of the leg

Each of the many bones of the lower extremity is at risk for fracture. Leg fractures also may involve the knee joint, and treatment depends upon the type of fracture. Similarly, fractures of the lower leg (tibia and fibula) and talus (the most proximal bone in the foot) may involve the ankle joint.

Fractures and dislocations of the foot may be as complex as the hand. Because of the anatomy, they may also be more difficult to diagnosis on plain X-rays.

Broken toe

Broken toes are a common fracture and may be diagnosed by history and physical examination. X-rays may or may not be needed depending upon the clinical situation.

Broken shoulder

X-ray of a broken collarbone (clavicle)
The clavicle (collarbone) fracture is one of the most commonly seen broken bones, fracture of the humeral head (the ball) is quite common an older person who falls.

Depending upon the amount of comminution (into how many pieces the humeral head breaks) surgery may or may not be required. Initial treatment usually begins with a sling.

The scapula or shoulder blade is a flat bone and very difficult to break. The mechanism is usually a direct blow. Any scapula fracture needs to be evaluated for related injuries.

What are the signs and symptoms of a broken bone?

Broken bones hurt. The lining of the bone (periosteum) is rich with nerve endings that can cause pain when inflamed; and the muscles surrounding the fracture go into spasm to prevent movement of the fracture site, and this spasm may intensify the pain.

Bones have a rich blood supply and will bleed when injured. This will cause swelling and the blood that seeps into the surrounding tissue will also cause further pain. The discoloration due to the blood can show up as dark red or purple bruise in the area of the fracture site.

Because muscles and tendons may not be damaged, the person may be able to move the injured extremity. For that reason, just because you can move the injured area, doesn't mean it's not broken.

If there is damage to a nearby artery, the injury may be cool and pale (distal to the injury), and if there is nerve damage, there may be numbness (distally).

When should I call a doctor if I think I have broken a bone? Most broken bones require medical care but the urgency of that care depends upon the type of fracture and the circumstances.

How is a broken bone diagnosed?
The doctor will take a history of the patient's injury, examine the injury, and look for potential other injuries that may have occurred. The skin surrounding the injured area is inspected to look for a laceration, scrape, or skin tear.
The area of tenderness and swelling will be evaluated to identify the injured bone.
The type of X-ray that is ordered depends on the specific injury. Sometimes plain X-rays do not identify the injury. If the doctor is still concerned, CT scan or MRI might be ordered.

Fractures in children

Fractures may be difficult to diagnose in children because bones have not completely formed. Many parts of developing bone are comprised mostly of cartilage and have yet to have calcium deposited in them. Growing bone also has growth plates that may mimic or hide fractures. On occasion, the diagnosis of a fracture is made clinically based upon physical exam, even if the X-rays do not show an injury.

What is the treatment for a broken bone?
The initial treatment of a fracture begins with stabilization and immobilization. In the field RICE (rest, ice, compression and elevation) may help make the patient more comfortable and prevent the fractured bones from moving. Often the pain associated with a fracture is due to spasm of the muscles surrounding the fracture site trying to prevent movement. Splinting may help relieve some of that pain. Depending upon the injury, EMS providers may consider traction to help with stabilization and pain control.

For non-open fractures, or other fractures that can be treated without emergency surgery, the goal is to immobilize the injury to maintain anatomic alignment to allow the bone to heal.

Bone heals in three stages.

Reactive stage: The blood clot that forms at the fracture site begins to organize and the body's building blocks start to bridge the gap between the two ends of the broken bone.

Repair stage: Specialized cells located in the outer lining of the bone (periosteum), begin to form a lattice work or grids of cartilage and bone, called a callus, which spans the fracture. More bone is laid down to provide strength to the area.

Remodeling phase: Over the next few years, the body will attempt to resculpt this mass of bone into it's original size and shape. In the emergency department, walk in clinic, or doctor's office, the extremity is usually splinted using a combination of soft padding, casting material (plaster, fiberglass), and ace wraps. This splint is not circumferential like a cast, because a fracture has the potential for swelling of the surrounding tissues, and if a tight cast were in place, that swelling could cause complications including significant pain and potential blood supply issues.

Once the patient is discharged, their instructions are to elevate the injury and ice the area, even with the splint, to help decrease swelling and inflammation.

After a few days, once the initial swelling has resolved, a circumferential cast may replace the splint and will be worn until the fracture is healed. The time frame for healing depends upon the type of fracture and its location. X-rays may be used to help determine when it is time for the cast to be removed.

Finger and hand fractures may be more complicated. The hand is a complex web of tendons, blood vessels, and nerves that allow fine motor function. What might be acceptable healing and alignment in an arm or leg may not be appropriate in a hand. Some finger injuries need nothing more than a metal splint or buddy taping one finger to another for support, while others will need surgery. The type of treatment will depend upon the type of injury.

Most toe injuries heal very well own and need nothing more than buddy taping one toe to another for support.

The treatment for rib fractures involves pain control so that the patient can take deep breaths and allow the lung to expand beneath the injury site to prevent pneumonia. Rib injuries are not wrapped or bandaged to help with pain control because this will limit their movement, and prevent lung expansion. Because of this, rib fractures generally take 4 to 6 weeks to heal and may cause pain throughout the healing process.

What about surgery for a broken bone?
The decision to operate on a fracture depends upon the type of fracture, whether it can heal in good alignment on its own, and whether other potential complications exist.

Sometimes patients are taken to the operating room for a closed reduction (resetting of the bone) and splinting of the fracture. When a fracture is markedly displaced and misaligned, it may be too painful to move or manipulated the bone without an anesthetic.

If it appears that the fracture is unstable and cannot be held in place and in good alignment with just a splint or cast, an open reduction and internal fixation (ORIF) may be needed. An incision is made so that the bony pieces can be identified and aligned. Metal plates and screws, wires or rods may be used to stabilize the fracture. The hardware may be left in place forever or it may be there only temporarily until the fracture heals. Hip fractures almost always require ORIF to allow the patient to heal and regain the ability to walk.

Surgery may be required in situations where there is associated injury to arteries and nerves and they need to be repaired or decompressed.

Open fractures often have to go to the operating room to be washed out to prevent infection of the bone (osteomyelitis).

How can fractures be prevented?
Many broken bones occur because of accidents in the home, at work or at play, and not all may be preventable. Using proper safety equipment and precautions may minimize the risk of injury, but it cannot be completely eliminated.

As we age, there is an increased risk for falls at homes and some preventive steps may help reduce fall risks. These include:
Make certain that lighting is adequatev Shoes should not be slippery
Loose rugs or uneven floors should be repaired
High traffic areas like from the bed to the bath or from the kitchen to the living area need to be clear from hazards like excess furniture, extension cords, or boxes
Bathrooms should have nonslip mats on the floor and in the bathtub or shower
Install handrails for stairs and grab bars in the bathroom Bones also get old as we age and the management of osteoporosis is a life-long commitment. Increasing calcium content in bone will decrease the risk of spontaneous fracture, and also may make bone strong enough to potentially withstand an injury that otherwise would result in a fracture. Ways to prevent osteoporosis include:

Increase weight bearing exercise

Make sure you are getting the right amount of calcium and Vitamin D in the diet. Take supplements if necessary.

Do not smoke

Avoid excess alcohol intake

What is the prognosis for a broken bone?
Fractures are a common injury, but the prognosis depends upon the bone that is broken, the location of the break, whether any complications exist and the underlying medical condition of the individual. Most arm and leg fractures heal well, and the goal is for the person to return to their baseline level of activity.
Trauma and Fractures

A wide range of fractures are managed in the emergency department. The codes for fractures have greatly expanded in ICD-10-CM due to the specificity of site, inclusion of laterality, nature of the fracture (transverse, oblique, comminuted, segmental, etc) and seventh character extender additions. To accurately assign fracture codes the documentation must also include:?Type of fracture—open or closed, including the Gustilo classification for open fractures?Stage of healing—routine or delayed?Complications—nonunion or malunionICD-10-CM traumatic fractures are coded classified in Chapter 19, Injury, Poisoning and Certain Other Consequences of External Causes.
ICD-10 code description

S 02 Fracture of skull and facial bones
S 12 Fracture of neck
S 22 Fracture of rib(s), sternum and thoracic spine
S 32 Fracture of lumbar spine and pelvis
S 42 Fracture of shoulder and upper arm
S 52 Fracture of forearm
S 62 Fracture at wrist and hand level
S 72 Fracture of femur
S 82 Fracture of lower leg, including ankle
S 92 Fracture of foot, except ankle
T 02 Fractures involving multiple body regions
T 08 Fracture of spine, level unspecified
T 10 Fracture of upper limb, level unspecified
T 12 Fracture of lower limb, level unspecified
T 142 Fracture of unspecified body region

Injuries to the head (S00-S09)
Injuries to the neck (S10-S19)
Injuries to the thorax (S20-S29)
M 907 Fracture of bone in neoplastic disease
M 966 Fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate

M 484 Fatigue fracture of vertebra
M 495 Collapsed vertebra in diseases classified elsewhere
M 80 Osteoporosis with pathological fracture
M 843 Stress fracture, not elsewhere classified
M 844 Pathological fracture, not elsewhere classified

2-part displaced fracture of surgical neck of left humerus, S42.222A
2-part displaced fracture of surgical neck of left humerus, S42.222B
2-part displaced fracture of surgical neck of right humerus, S42.221A
2-part displaced fracture of surgical neck of right humerus, S42.221B
2-part displaced fracture of surgical neck of unspecified hu S42.223A
2-part displaced fracture of surgical neck of unspecified hu S42.223B
2-part nondisplaced fracture of surgical neck of left humeru S42.225A
2-part nondisplaced fracture of surgical neck of left humeru S42.225B
2-part nondisplaced fracture of surgical neck of right humer S42.224A
2-part nondisplaced fracture of surgical neck of right humer S42.224B
2-part nondisplaced fracture of surgical neck of unspecified S42.226A
2-part nondisplaced fracture of surgical neck of unspecified S42.226B
3-part fracture of surgical neck of left humerus, initial en S42.232A
3-part fracture of surgical neck of left humerus, initial en S42.232B
3-part fracture of surgical neck of right humerus, initial e S42.231A
3-part fracture of surgical neck of right humerus, initial e S42.231B
3-part fracture of surgical neck of unspecified humerus, ini S42.239A
3-part fracture of surgical neck of unspecified humerus, ini S42.239B
4-part fracture of surgical neck of left humerus, initial en S42.242A
4-part fracture of surgical neck of left humerus, initial en S42.242B
4-part fracture of surgical neck of right humerus, initial e S42.241A
4-part fracture of surgical neck of right humerus, initial e S42.241B
4-part fracture of surgical neck of unspecified humerus, ini S42.249A
4-part fracture of surgical neck of unspecified humerus, ini S42.249B
Last Updated: November 13, 2020