Fracture & Trauma Surgery

Not every fracture needs an operation

It is worth saying first, because it is the most common misunderstanding. A great many broken bones heal perfectly well in a plaster cast or a brace. Bone is one of the few tissues in the body that repairs itself back to full original strength, and where a fracture is stable and sitting in a good position, letting it do so is the right treatment.

Surgery becomes the better option when the position is unacceptable, when the fracture will not stay put, when a joint surface is involved, or when fixing it lets you move and use the limb weeks earlier than immobilising it would.

How fractures are fixed

Plate and screws

A metal plate contours to the bone and screws hold the fragments to it. Preferred where a joint surface needs to be rebuilt precisely, and around the wrist, ankle, elbow and shoulder.

Intramedullary nail

A rod passed down the hollow centre of a long bone and locked with screws at each end. Excellent for the thigh and shin because it shares load with the bone and often allows walking almost immediately.

Screws alone

For fractures where two clean fragments can be compressed back together, with the smallest possible exposure.

External fixator

A frame outside the skin, connected to the bone with pins. Used in severe injuries with damaged soft tissue, or as a temporary measure to stabilise a limb until definitive surgery is safe.

Hemiarthroplasty or replacement

For some hip fractures in older patients, and some complex fractures near the shoulder, replacing the broken end is more reliable than trying to rebuild it.

Most fixation is done with live X-ray guidance in theatre, which allows the fracture to be reduced and the position confirmed to the millimetre before anything is fixed — and, in many cases, allows it to be done through much smaller incisions than would otherwise be needed.

Fractures that were never fixed properly

A substantial part of complex trauma work is not fresh injury but its aftermath: a bone that healed in the wrong position, or never healed at all. Both are correctable, and both are worth having assessed even years later.

Risks

• Infection, which is more likely in open fractures where skin was broken at the time of injury.
• Delayed union or non-union, substantially more likely in smokers and in diabetics with poor control.
• Metalwork irritation, particularly where a plate sits close under the skin — the ankle, wrist and collarbone.
• Stiffness in the neighbouring joints, which is the reason movement is started as early as fixation allows.
• A blood clot in the leg after lower-limb injury or surgery.
• Nerve or blood vessel injury, uncommon but higher in complex and open fractures.
• Post-traumatic arthritis where a joint surface was involved, which good reduction reduces but cannot always prevent.
• The need for further surgery — graft, revision fixation, or removal of metalwork.

Things that genuinely change how fast you heal

• Stopping smoking. Nicotine constricts the small blood vessels that fracture healing depends on, and it is the single largest modifiable risk for non-union.
• Controlling diabetes. Blood sugar affects both bone healing and infection risk.
• Adequate protein, vitamin D and calcium — bone repair is a construction project and it needs materials.
• Moving everything you are allowed to move. Stiffness in the joints around a fracture causes more long-term trouble than the fracture itself.
• Attending every follow-up X-ray. Problems caught at six weeks are far easier to solve than problems found at six months.