New Treatments in Fracture Care
By Scott M. O'Connor, M.D.

Orthopedic surgeons treat millions of fractures each year in the United States . Traditional methods of surgical fracture repair developed over the past century provided reliable results with regard to fracture union (healing) and functional recovery. Recent innovations in fracture care have been developed that have the potential to increase long bone healing rates. Other benefits include earlier return to functional activities, shorter hospital stays, and decreased incidence of nonunion.

Healthy bone is made up of living tissues called cone cells, which are always regenerating and replacing dead or injured cells. Long bones, including the femur (thigh), humerus (arm), and tibia (leg), are spongy on the inside and hard, but not brittle, on the outside, providing a living structure capable of bearing a great deal of weight, yet able to self-repair if the weight-bearing capacity is exceeded. When excessive force is applied to a long bone, a fracture may occur. Different fracture patterns occur depending on the direction and magnitude of the force applied.

The fracture site begins the healing process when bleeding occurs at the bone ends. The blood forms a clot, and new blood vessels form which carry large white blood cells, called macrophages, to the fracture. These cells remove unneeded debris and bacteria from the area. Fibroblasts then arrive on the scene and a rubbery mesh of collagen, called callous, is developed, which initially loosely stabilizes the fracture site. Over time the callous is matured by a mineralization process, in which calcium hydroxyapatite crystals are deposited, and the fracture is healed.

Fractures are classified and treated according to the amount of displacement, or separation of the bone ends at the fracture site. Most fractures are non-displaced, and require only splint or cast immobilization until the bone is healed. Many fractures require reduction. Reduction is the procedure in which the fractured bone ends are realigned appropriately. Closed reduction involves obtaining bony alignment via manipulation of the structure without incising the skin, and is done with or without anesthesia. Other fractures have enough displacement (separation) of the bone ends, or angulation (misalignment) of the bone fragments to require a surgical procedure in which an incision is used to properly expose and subsequently align the fracture. This is called open reduction. Often pins, screws, plates, rods, nails, or wires are used to hold the reduced fragments in place until bony union occurs. This is called internal fixation. Occasionally external fixation may be required in which pins are placed into the bone through the skin, and are connected to rods or bars outside of the skin. This construct stabilizes the fracture externally until healing occurs, and is then removed.

Distal radius (wrist) fractures commonly occur from a fall on an outstretched hand. Displaced fractures most often have been treated with closed reduction and cast application, or with an external fixator. Recent improvements in plate and screw design have made open reduction and internal fixation (ORIF) an attractive option. Previously, difficult fractures often required plates on both the front and/or the back of the wrist, often leading to increased postoperative stiffness and an increased chance of infection. New plate and screw designs allow fracture fixation despite lighter and smaller implants. This allows earlier range of motion exercises, which facilitates rehabilitation, and potentially improves ultimate patient satisfaction.

A key feature of these new plates and of other recently developed plating techniques is the concept of locking plates and screws. In a conventional plate and screw construct, the screws slide through a hole in the plate, and are then screwed into the bone, holding the plate against the bone. Several screws are placed through the plate on the either side of the fracture, providing secure internal fixation of the screws to the bone. In the case of a locking system, both the screw head and the plate hole also have threads, allowing the screw head to be fixed to the plate. This provides more secure fixation of the fracture-implant construct, and has other potential advantages, including better fixation in osteoporotic bone. Additionally, the locking plate may allow the surgeon to work through a smaller incision, which can better preserve the blood supply to the bone, and can reduce the risk of non-union of the fracture.

The general concept of less invasive fracture surgery is a driving force both in the development of new fracture implant designs and surgical techniques. Locking plates and screws have also shown promise in treating difficult fractures of the upper humerus, shoulder, and knee joints, and in the lower leg. The technique of percutaneous plating involves surgical placement of plates and screws through relatively small incisions on either end of the fracture using intraoperative radiographic assistance. This "indirect" approach reduces the exposure of the bone, and preserves more of its blood supply, by reducing the amount of soft tissue stripped from the bone. The "biologic" method of reduction may improve the rate of healing, decrease the need for supplemental bone grafting, and lower the incidence of infection and other complications.

Hip fractures occur very commonly in the elderly population due to traumatic falls. Osteoporotic bone contributes both to the genesis of these fractures, and also can affect the resultant treatments and outcomes. These fractures are often comminuted (in many pieces) and may be difficult to reduce. Standard plate and screw treatment can be problematic, since the weak bone may not hold screws well, and the construct may not allow the patient to bear full body weight without danger of the screws pulling out of the bone, or cutting through the relatively soft bone. Newer intramedullary (inside the bone) rods are designed especially for osteoporotic hip fractures, and can provide solid internal fixation, allowing elderly patients to begin full weight bearing with a walker immediately. This greatly improves immediate mobility, which can be a key factor in reducing the rate of postoperative complications due to decreased activity, such as pneumonia, decubiti (bed sores), and blood clots.

Fractures are unfortunate, but fairly common occurrences. Treatment methods are variable, and depend on various factors such as patient age, bone quality, fracture pattern and location, and surgeon preference. Proper exercise and a diet with adequate calcium and vitamin D content can increase bone mass and significantly decrease the risk of fracture. Bone density tests, such as DEXA scans, are widely available, and can help to identify those at increased risk of fracture due to mildly (osteopenia) or severely (osteoporosis) decreased bone mass.

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