Pathoanatomy of fracture, soft tissue condition and patient conditions are the main factors that affect outcome of fracture treatment.
The pathoanatomy of the fracture is defined by the location, morphology, and degree of displacement of the fracture and has a marked influence on the outcome of the fracture treatment. As important as the pathoanatomy of the fracture itself is the state of the soft tissues.
A careful analysis of the pathoanatomy of the fracture and the state of the soft tissues enables us to predict the expected outcome.
Pathoanatomy of the Fracture
The natural history of the fracture is influenced by the location of the fracture, whether it is in the diaphysis, the transition zone extending into the metaphysis, or the epiphysis, with or without joint involvement.
An intraarticular fracture assumes significance and overriding importance over other injuries as the result will depend upon obtaining a stable anatomical reduction and early motion of the joint.
Metaphysis and Transition Zone
Fractures in the metaphysis or in the transition zone between the metaphysis and the diaphysis may be caused by compressive or tensile forces. If caused by compressive forces, the fractures are often crushed and axially malaligned.
Transition zone fractures caused by shear forces may be due to direct or indirect trauma.
A shearing injury through the metaphysis or the transition zone between the metaphysis and diaphysis is therefore a high-energy one and may be associated with considerable instability and displacement.
Cancellous metaphyseal bone heals quickly if compressed and slowly if displaced. Therefore in case of displacement and compression, open reduction and compression of some fractures in the metaphysis or the transition zone may be desirable.
Unstable, displaced diaphyseal fractures often require surgery in most of the long bones as the maintenance of an acceptable reduction may be difficult and union may be delayed by non-operative means.
Morphology of Fracture
The morphology of the fracture will suggest the type of injury that caused it, whether transverse, short oblique, or spiral, displaced or undisplaced, comminuted or not.
Transverse and short oblique fractures, are indicative of a greater force than are spiral fractures. Marked comminution and gross displacement, suggesting complete disruption of the soft tissue, emphasize the violent nature of the injury.
Soft Tissue Injury
The state of the soft tissues is at least as important as the morphological appearance of the fracture.
Greater the trauma, the more likely the presence of major soft tissue damage.
The soft tissue damage may be overt, with an open wound, or could be in form of massive swelling, ecchymoses, and instability of the fracture.
Other Injuries to the Limb
The presence or absence of other injuries in the same limb will greatly affect the natural history of a fracture.
The presence or absence of an arterial or nerve injury or an early compartment syndrome will greatly influence the decision-making in the management of a fracture.
Age is important at the two extremes.
In skeletally immature patients, open reduction of the is almost never indicated.
In older individuals, on the other hand, though open reduction and internal fixation are strongly indicated and important, an extremely osteoporotic bone in which it is impossible to achieve stable internal fixation or medical conditions which could affect patient’s outcome may force the treating physician to choose non-operative treatment.
The patient’s occupation and recreational habits should be known so that there can be no major disparity between the expectation of the patient and the treatment offered. For example expectations of an athlete are different from that of the one who leads a sedentary life.
Patients with injuries to many body systems have a high risk of developing respiratory complications. If these patients are rapidly mobilized, especially in the upright position, many of these complications may be prevented or reversed.