Fracture Care and General Orthopedics
Orthopedic surgery is the surgical subspecialty that focuses on disease and disorders of the musculoskeletal system. Orthopedic surgery in itself is quite broad, covering everything from sprains and strains to broken bones and replacement of joints. Surgeons who specialize in orthopedic surgery can choose to further focus their practice through additional surgical training beyond that required of general orthopedic surgeons, in areas such as Orthopedic Sports Medicine, Pediatric Orthopedics, Orthopedic Oncology, Orthopedic Traumatology, Orthopedic Spine Surgery, and Hip and Knee Replacement, just to name a few.
As old as antiquity, healers have attempted to help the ill and injured who suffered from hurt and harm incurred during everyday life, work, or even battle. Ancient Egyptians are credited with developing the first cast for a broken bone (or what eventually developed into today’s cast) when they poured a mixture over an injured extremity which was framed so as to hold the blended concoction until it cured or hardened. World War II created medics skilled at providing diagnosis and medical care that were the genesis for today’s Physician Assistants (PAs) that sometimes help the orthopedic surgeon both in the office and in the operating room. German surgeon Gerhard Kuntscher was almost tried for war crimes after it was discovered that he was responsible for placing metal rods down the broken femurs (thigh bone) of captured US pilots who had suffered fractures of the body’s longest bone, until it became apparent that the new technique actually resulted in better and more rapid healing of the bone and became today’s accepted standard. Once physicians rose to become the accepted authority in medical care and began to specialize in such areas as pulmonology, internal medicine, obstetrics and gynecology, pediatrics, etc., it was the surgeons who took greatest interest in attending to disorders and injury of the skeleton, muscles, and what kept them all working together. The Civil War, World Wars I and II, the Korean War and Viet Nam all increased the need for attention to battlefield injuries and life-saving measures required as a result. It wasn’t long until the focused study of the musculoskeletal system was born of the surgical specialty, the orthopedic surgeon.
Perhaps the most common injury that the orthopedic surgeon is called on to treat in today’s medical practice is a fracture. Contrary to popular belief, the word “fracture” is not an indication of an injury of a lesser severity than a “break.” Rather, the two words are used interchangeably with regards to a broken bone. Nor does a fractured bone necessitate surgery in all cases. Care of the patient as an individual is an important concept in medicine in general; no two people are alike, and the same treatment option is not necessarily the right choice for different patients, even with the same fracture. Pre-existing medical conditions (comorbidities), associated risk factors, and even patient preference are all important considerations in deciding the best way to treat a fracture. Available options include nonoperative management or operative intervention through surgical stabilization. Both are viable alternatives to achieving healing of the broken bone.
Nonoperative Fracture Management
Many fractures can be treated nonoperatively. Nonoperative, as one would reason, is the method of monitoring fracture healing without involving surgical options. An example would be a relatively well-aligned fracture of a wrist in a child who falls at school and X-rays indicate that an incomplete buckle-type fracture has resulted. Such a patient would reasonably be a candidate for short arm fiberglass casting (a cast that extends from the elbow to the wrist). The cast acts to stabilize the fracture while it heals. The patient would have the cast applied, be instructed on weightbearing restrictions, and undergo regular follow-up visits to monitor healing. If healing progresses unremarkably, the cast would be removed after healing was evident and replaced by a splint until healing was complete.
Other examples of nonoperative management would include use of a sling for an uncomplicated fracture of the clavicle (collarbone) or scapula (shoulder blade), splinting for a broken finger or toe, a hard-soled (postoperative) shoe for an isolated fracture of a foot bone, or dynamic splinting of a finger for a tendinous avulsion fracture from a sporting mishap. The point is, there is often both an operative and nonoperative option for care of a fracture.
Operative Fracture Management
Certain types of fractures are considered inherently unstable. Fractures about the hip are an example of this. Nonoperative management of hip fractures has shown very poor results, with lack of healing and eventual need for surgery being a common result. Therefore, fractures of the hip are generally treated surgically unless there are considerable factors in which the risks of surgery are considered to outweigh its potential benefits. Other fracture types may or may not have adequate stability to be considered for nonoperative management. An example might be a bone which has fractured at an angle. The pull of the attached muscles will often cause the bone to move so that acceptable healing cannot take place, and surgical stabilization may be required. Sometimes, such fracture types may undergo a trial of nonoperative management with close follow-up so that surgery may be elected earlier rather than later if need be.
There are different types of surgical stabilization for fractures, but all share the common characteristic that the surgeon uses rigid implants to stabilize the broken bone ends with them held closely enough together to facilitate healing. One method of surgical stabilization is plate-and-screw fixation. With plate-and-screw fixation, the surgeon must cut the skin over the fractured bone and expose the broken bone ends. A plate is then applied to the side of the bone and attached by screws drilled into the bone to hold the plate in place, much like a board might be applied alongside another broken board and screws used to hold it in place. The significant difference is that the plate-and-screw fixation is performed strictly for the bone to be able to heal while being held in place by the surgical construct. Once the bone has healed, the plate and its associated screws no longer serve a purpose. Most commonly, however, they are left in place rather than removed to avoid the risks associated with undergoing a second surgery to remove the components.
Intramedullary rod fixation is another surgical option for stabilization of a fracture. To understand how intramedullary fixation works, consider a long bone (such as the thigh bone, or femur) as tube, much like that cardboard center found in after the last paper towel has been used. The outer perimeter of the bone is hard, like the cardboard of the paper towel tube. The inner portion of the bone is still bone, but of a softer type. In intramedullary stabilization, the surgeon utilizes a drill to clear out a path in the softer, central bone and pass an intramedullary rod made of metal down the path in the center of the bone. This acts to align the fractured bone and allow it to heal. The drilling of the path actually helps to stimulate healing within the bone, and so is associated with very good outcomes for fracture healing. And unlike plate-and-screw fixation, intramedullary rod fixation can often allow for the surgeon not to have to expose the actual area of the fractured bone during surgery. Although this is not always possible, studies have demonstrated that avoiding disruption of the natural healing environment brought about by a fracture can be beneficial for healing. Another benefit of intramedullary fixation is that patients are often allowed to begin gentle use of the fractured extremity much sooner after surgery than might be possible with other forms of surgical fixation.
Another method of surgical fixation is known as external fixation, or “Ex-fix.” External fixation, as you might guess, refers to stabilization of a fracture by way of an external construct. During surgery, the fractured bone ends are aligned and held in place while pins are placed through small incisions in the skin to control their stabilization. The parts of these pins that remain outside the skin are attached to a rigid metal rod (sometimes two rods) and held with strong clamps. This rigid construct holds the pins, and by extension, the broken bone ends, still so that healing can take place with the bone properly aligned. External fixation brings about particular challenges, including pin site care and regular follow up where the surgeon can monitor the construct for any infection, make sure the construct remains rigidly fixed, and evaluate X-rays for expected healing.
Orthopedic Surgery Beyond Fractures
Although the care of broken bones makes up a large part of the medical practice of the orthopedic surgical specialist, it is not the only thing we care for. Tendon and ligament injuries, sprains and strains, and joint injury are common complaints for which patients seek out the expert advice of the orthopedic surgeon. Sometimes, surgical repair or even replacement may be the right option, and in others, a nonsurgical course of care and follow-up may be in order.
Being human means incurring injury or persistent pain at some point. We all take over-the-counter pain relievers when we stub a toe or have a painful joint, but when conservative measures fail to result in relief, we encourage patients to come to us for a professional opinion. Just because you may have an injury or damage for which surgery is an option, no one is going to hold you down and perform surgery against your will. The surgeon is there to provide you with options, and together, patient and surgeon will decide on the best course of action. For all patients who suffer injury or illness where the musculoskeletal system is involved, the orthopedic surgeon is there to help.
In the specialty of orthopedic surgery, great advancements have been made. We are, however, still and ever shall be learning. As alluded to before, what is past may well be only the prologue to what is yet to come for even greater advances in orthopedic surgery and fracture care. What the future brings we shall discover together, as patient and surgeon.
Christopher Blair, DO, MBA
Texas Orthopedic Surgery Consultants