The method of fracture fixation used in each case is dependent on the exact nature of the fracture. Where there is anything other than a 'simple' fracture, bones will need to be re-aligned – that is put back into the correct position – and stabilised. This is what is referred to by the medical term 'reduction'. This can be achieved without surgery (i.e. via a 'closed' approach) or using surgery (an 'open' approach).
Closed mechanisms of fracture fixation include using only splints and casts to stabilise the bone(s). Open mechanisms often involve the fixing of implants such as plates, rods, nails, wires and screws (generally made of titanium and / or steel) designed to stay in the body indefinitely.
Open 'conventional' surgery is the standard approach, but more and more of these procedures are being conducted either partially or wholly as arthroscopic (i.e. minimally invasive) procedures. Open mechanisms are often referred to as 'ORIF' procedures, where this stands for 'Open Reduction Internal Fixation'.
Which method is selected varies in each case and in all cases the recommended method is fully discussed with the patient before proceeding with surgery.
The following is a brief overview of the more common types of fractures and the types of approaches generally taken.
Hand
Fractures to the bones in the fingers can often be dealt with by the fitting a splint, whereas serious fractures in other parts of the hand may need fixation. Surgery is required where a fracture has displaced and needs to be put back into position ('reduced') using screws and plates. There are many different ways in which the bones of the hand can fracture and so x-rays are required to determine the best course of action.
Wrist
If the fracture is acute, some deformity will be evident, and x-rays are generally taken to determine the exact nature of the injury. Where there is little displacement a 'backslab' (a cast applied to only one side of a limb) or a full cast may be used and the patient then referred for orthopaedic review. Where fractures are more significant, surgery may be needed to fit one or more plates to reduce the fracture(s).
Elbow
Fractures where there has been no relative movement of the affected sections of bone can be treated by applying a backslab and putting the arm in a sling. Surgery may be required where there has been some displacement, where generally wires are fitted to reduce the fracture. In more severe elbow fracture cases, other tissue such as nerves and arteries may be affected, in which case urgent surgery will be required. Precise diagnosis is via x-ray and in some cases a CT scan may also be required.
Shoulder
High energy trauma often results in bones fracturing into many different pieces (referred to as 'comminution') at the point of impact. Some fractures, such as simple impaction fractures where the ball 'head' at the end of the humerus bone in the upper arm pushes into the humerus, do not require treatment, however in many cases sections of the upper humerus fracture and surgery to perform any reduction and fixation may be necessary.
See also Shoulder Fracture Management.
Hip
Diagnosis of hip fracture is generally via x-ray, however incomplete hip fracture may be missed on x-ray, in which case an MRI scan may be required to detect this. Some fractures can be treated non-surgically, but most will require surgery (fracture fixation using plates, screws or nails; or hip replacement).
Knee
Knee fractures generally occur in vehicle accidents or where there is any direct trauma to the knee. A physical examination followed by x-rays will allow an accurate diagnosis. Where there is no displacement of the bone segments surgery may not be required, but a cast or brace will need to be worn. If there is some bone displacement, surgery will be required.