Fracture Fixation

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Introduction

A fracture is a break in the bone, usually occurring as a consequence of an injury. Some of the bone fractures are stable and for adequate healing, they may only need a period of immobilisation or restricted weight-bearing. Many fractures, however, need a formal fixation to stabilise the bone fragments, prevent any deformity and promote fracture healing. An adequate, fracture–specific surgical technique is necessary and may involve the use of various implants, such as plates, screws, pins, rods, nails or external fixation devices, to hold the bone fragments in place. The primary goal of fracture fixation is to restore the normal alignment of bones and joints, to facilitate bone healing, to allow for early motion and physiotherapy and ultimately to restore the function of the injured limb.

Indications and Contraindications

Indications

Fracture fixation is indicated in various scenarios, including:

Long bone fractures: Long bones easily displace after fractures; they often need primary fixation to restore alignment or to prevent secondary deformity.
Fractures difficult to heal: some bones are known to heal with difficulty or with delay, they need primary fixation to promote fracture healing.
Complex Fractures: When fractures are highly unstable, involve multiple bone fragments, or occur near joints, surgical fixation is necessary to ensure proper alignment and healing.
Open Fractures: Fractures accompanied by wounds are at risk of infection. Surgery is necessary to manage contamination, address wound and soft tissue injury and stabilize the fracture.
Delayed unions or nonunions: Some fractures heal too slowly. Surgical stabilisation can promote bone regeneration.
Pathological Fractures: Fractures occurring in bones weakened by diseases such as tumours or osteoporosis will require surgical fixation to manage pain and prevent further deformity.
Joint Fractures: Fractures involving joints often need surgical fixation to maintain joint congruity and prevent arthritis.

Contraindications

There are instances where fracture fixation is contraindicated:

Medical Instability: For patients with significant medical comorbidities or shortly after severe injury, surgery or anaesthesia might carry great a risk of complications. Prior to definitive surgery, the patient needs optimisation and stabilisation of their general condition.
Severe swelling: Severe swelling after an acute trauma carries a high risk of soft tissue breakdown and serious infection. Surgery should be delayed.
Uncontrolled Infections: Active infections at the surgical site hinder adequate soft tissue healing and carry a risk of inducing bone infection.
Poor Blood Supply: In areas with compromised blood supply, bone and soft tissue healing may be compromised.

Benefits and Risks

Fracture fixation surgeries can provide several benefits for patients recovering from fractures. However, these procedures also carry certain risks. Here are the benefits and risks of fracture fixation surgeries:

Benefits of Fracture Fixation Surgery

Stabilisation: Fracture fixation surgery provides immediate stabilisation of the broken bone, reducing pain and preventing further displacement of the fracture. This helps promote better healing and accelerates mobilisation.
Alignment: The surgery ensures that the fractured bone is properly aligned, which is essential for optimal healing and functional recovery.
Accelerated Healing: Fixation hardware, such as screws, plates, or rods, helps hold the bone fragments together, allowing for faster healing and reducing the risk of non-union (failure of the bone to heal).
Restoration of Function: By correctly aligning and stabilising the fracture, these surgeries aim to restore or preserve the function of the affected limb or bone, enabling patients to regain mobility.
Reduced Pain: Proper fixation of the fracture often leads to reduced pain and discomfort, facilitating the patient’s recovery and rehabilitation.
Lower Risk of Complications: Fracture fixation can reduce the risk of complications associated with delayed or non-surgical management, such as compartment syndrome or nerve damage.

Risks of Fracture Fixation Surgeries

Infection: Surgical site infection is a potential risk, although the use of sterile techniques and antibiotics can help minimise this risk.
Hardware Problems: Implants used for fixation can sometimes cause issues, such as loosening, migration, or irritation of the surrounding tissues.
Non-Union or Malunion: While surgery aims to promote proper healing, there is still a risk of non-union (failure of the bone to heal) or malunion (improper healing), especially if the patient’s overall health is compromised.
Nerve and Blood Vessel Damage: There is a risk of damaging nearby nerves or blood vessels during the surgical procedure, which can lead to sensory or motor deficits.
Blood Clots: Surgery can increase the risk of deep vein thrombosis (DVT), a blood clot in the deep veins of the leg with its catastrophic consequences. Blood-thinning medications and compression stockings may be used to mitigate this risk.
Anaesthesia-Related Complications: Patients undergoing fracture fixation surgery are at risk of complications related to anaesthesia.
Scarring: Surgery typically results in some degree of scarring at the incision sites. Scarring can vary in appearance and may be more or less noticeable depending on factors like wound care and healing.
Post-operative Pain: After surgery, patients may experience post-operative pain, which is typically managed with pain medication and careful post-operative care.
Restricted Mobility: Following fracture fixation surgery, patients may initially experience limitations in their mobility and function. Rehabilitation and physiotherapy are often necessary to regain strength and function.

Surgical Approach

The surgical is determined by fracture location, type, fixation method and coexisting injuries or patient’s comorbidities. The most common surgical approaches include:

Open reduction and internal fixation (ORIF) – usually with plates and screws,
Closed (or open) reduction and internal fixation – usually with intramedullary nails (IN) or minimally invasive percutaneous techniques (MIPO).
Closed, open or gradual reduction with external fixation device – usually monoliteral Ex Fix or ring fixator.

Pre-Surgery Information

The following is what can be expected prior to a Fracture Fixation Procedure

Patient Evaluation: A thorough assessment of the patient’s overall health, medical history, and orthopaedic condition. When necessary, your health might need optimisation and we may refer you to another specialist.
Medications: Inform your healthcare provider about any medications you’re taking, as some may need to be adjusted before surgery. You should stop taking aspirin or anti-inflammatory medications 10 days prior to the surgery. Also, you should discontinue any naturopathic or herbal medications during this period.
Imaging: X-rays, CT scans, and MRIs are used to evaluate the extent of damage and plan the surgery. CT scans are especially helpful in planning the surgical steps.
Skin preparation: The night before and on the morning of the operation, you will be asked to wash the leg with a sponge provided at the pre-admission clinic. If there is any suspicion of an iodine allergy, a Betadine Skin test might be used.
Bowel Prep: Glycerin suppositories will be provided at the pre-admission clinic, and you will need to administer them the evening prior to the surgery. An instruction leaflet will be given to guide them.
Patient education: During a physiotherapy assessment, a qualified physical therapist will provide you with personalised instructions on gait training, the use of crutches, and pre- and postoperative exercises. You will be fitted with crutches to take home and practise before the surgery.

On the day of the Surgery

Surgical paperwork will be administered by the nurses, and the anaesthetist will meet with the patient to ask a few questions.
A hospital gown will be given, and the operation site will be shaved and cleaned.
Betadine skin prep will be applied to the area above the operation site and wrapped.
All x-rays are to be sent with the patient to the theatre.

Surgical Procedure

The surgery

Anesthesia: General anesthesia or regional anesthesia (spinal, epidural etc.) is used to ensure a pain-free procedure.
Incision: An incision is based on the fracture’s nature and the fixation method, incision allows for implant insertion and/or for fracture reduction.
Fracture reduction: Fracture is reduced either directly or indirectly.
Fracture fixation: An appropriate implant is inserted onto (plates) or into (nails) the bone or over the whole limb (external fixator), with an aim to maintain the correct position of bone fragments.
Fracture alignment and stability of fixation are confirmed with x-rays.
Additional reconstructive procedures: if indicated, soft tissue repair or reconstruction is performed at the same time as fracture fixation.
Closure: The incision is closed using sutures. Dressing is applied and immobilisation in a cast or a backslab may be indicated.

Post-Surgery Information

Hospital Stay: A simple fracture fixation is usually processed as a day surgery. After a more serious surgery, you’ll typically be admitted to a hospital for several days for monitoring and initial rehabilitation.

Pain Management: Pain medications will be administered to keep you comfortable.

Immobilisation: When necessary, a cast, splint or brace may be used to protect your surgical site. The length of its use will depend on primary fracture, its fixation and other reconstructive procedures performed.

Weight-Bearing: When necessary, you will remain non-weight bearing for a period of time depending on your fracture type and its fixation method. Then you will commence weight-bearing gradually, with crutches, boots, or brace protection, following your surgeon’s instructions.

Follow-Up

Regular follow-up appointments with the team will help monitor your progress and address any concerns:

1 week postop: for wound check,

2 weeks postop: for sutures removal,

6 weeks postop: for x-ray assessment of healing progressing,

Later at 3 months postop, 6 months postop, 1 year postop and further annually with an x-ray will be mandatory.

Physical Therapy or Occupation therapy (for hand injuries)

A tailored rehabilitation program will help regain strength, flexibility, and mobility.

Return to Normal Activity and Sports

As the fracture heals and the bone remodels and strengthens, patients are gradually allowed to resume normal activities. The timeline for returning to light daily life activity ranges from 3 to 12 weeks, for sports between 3 and 12 months, and is based on the type and location of the fracture.

By restoring proper alignment and stability, fracture fixation allows for accelerated rehabilitation and return to normal activities as well as avoidance of serious complications such as delayed fracture healing, failure to heal at all or healing with deformity in the bone or joint. Recovery from fracture can take several months and commitment to rehabilitation as well as follow-up appointments is essential for optimal outcomes. Always consult with your healthcare provider for personalized guidance and recommendations.

Concerns

If patients are worried about their level of pain, experience significant bleeding, or notice fever or redness around the surgical site, they should contact the office immediately. If assistance is needed after hours, patients can contact the hospital where the surgery was performed, and they will contact Professor Al Muderis on their behalf.

Norwest Private Hospital: (02) 8882 8882

Macquarie University Hospital: (02) 9812 3000