Fracture Repair

Part of Surgery

Managing broken bones through reduction, immobilization, and rehabilitation to restore function.

Why This Matters

Fractures are among the most common serious injuries in any physical environment. Agricultural work, construction, falls, animal accidents, and conflict all produce broken bones regularly. A fracture that is not properly treated becomes a disability: shortened limb, permanent deformity, chronic pain, or non-union (the bone failing to heal at all). In pre-modern settings, a mal-united leg fracture was often a death sentence — the individual could no longer work, hunt, or flee danger.

Proper fracture management — reduction (aligning the bone), immobilization (holding it in place), and rehabilitation (restoring function) — can restore nearly full function even without x-rays, metal implants, or operating rooms. These techniques were developed and refined over thousands of years of pre-surgical medicine and remain valid today.

The key insight is that bone heals itself when given correct alignment and adequate immobilization. The healer’s role is to create the conditions for this natural process — the bone does the actual work.

Fracture Classification and Urgency

Closed fracture: bone broken, skin intact. Standard management. Time-sensitive (days, not hours).

Open (compound) fracture: bone broken, skin overlying fracture is breached. The bone may be visible or simply a wound communicating with the fracture site. Surgical emergency — infection in bone (osteomyelitis) is extremely difficult to treat and often leads to amputation. Requires immediate wound cleaning and fracture management.

Pathological fracture: bone broken through diseased bone (tumor, severe nutritional deficiency, chronic infection). Heals poorly; address underlying disease first.

Stress fracture: repeated microtrauma, often not fully broken. Rest is primary treatment.

Greenstick fracture (children): incomplete break along one cortex of a child’s flexible bone. Often angulated but not fully displaced; heals rapidly.

Assessment Before Treatment

Physical Examination

1. Deformity: is the limb visually abnormal (shortening, angulation, rotation)?
2. Swelling: rapid swelling suggests bleeding from fracture (especially femur — can lose 1-2 liters into the thigh)
3. Point tenderness: palpate along the bone — maximum tenderness marks the fracture site
4. Crepitus: gentle movement may produce a grinding sensation from bone ends (do not deliberately elicit this — it is painful and damages surrounding tissue)
5. Neurovascular check: pulse, sensation, and movement distal to the fracture

Specific tests:

• Suspected rib fracture: compress the chest from front and back — localized pain at the fracture
• Suspected femoral neck fracture (elderly): inability to externally rotate the hip, shortened limb
• Suspected spinal fracture: extreme caution — do not move the patient until assessed

Understanding the Fracture Pattern Without X-Ray

Clinical assessment can estimate the fracture type:

Transverse fracture (perpendicular to bone axis): typically from direct blow; relatively stable after reduction

Oblique fracture (diagonal): from twisting or angulated force; tends to be less stable

Comminuted fracture (multiple fragments): from high-energy injury (severe crushing); difficult to reduce, may require prolonged immobilization

Displacement: is the bone end displaced? Can you feel both ends separately? Significant displacement requires reduction.

Reduction: Aligning the Fracture

Reduction means moving the bone ends back into alignment. This must be done before casting.

When to Attempt Reduction

Reduce:

• Any fracture with significant angulation (>10-15 degrees)
• Any fracture with significant shortening
• Any fracture that would leave the bone end threatening skin (can cause skin necrosis and open the fracture)
• Any fracture with neurovascular compromise — urgent

Do not attempt reduction:

• Spinal fractures (risk of cord injury)
• Severely comminuted fractures where reduction is impossible to maintain
• Fractures near joints without surgical backup (may require open reduction)

Analgesia Before Reduction

Reduction without analgesia is cruel and counterproductive — pain causes muscle spasm that prevents reduction. Provide:

• Systemic analgesia (highest available)
• Local anesthesia: inject 10-20 mL of 1% lidocaine directly into the fracture hematoma if available
• Or regional nerve block
• As last resort: distraction techniques, alcohol

Reduction Technique

The general principle: gentle longitudinal traction (pulling the distal fragment along the bone axis) disimpacts the fracture, then the bone is guided back to alignment.

Two-person technique for forearm fracture (example):

1. One person stabilizes the upper arm, gripping firmly above the fracture
2. Second person grips the hand/wrist
3. Apply steady, firm, increasing traction — pull the hand away from the body along the bone axis
4. After 30-60 seconds of steady traction, the muscle spasm relaxes and fracture disimpacts
5. With traction maintained, guide the forearm into correct alignment — compare to uninjured side
6. Reduction confirmed by: restored alignment compared to uninjured side, soft tissue contour returning to normal, often a palpable “clunk” as bone ends re-engage

Traction for femur fracture: The thigh muscles are extremely powerful — 40-60 kg of muscle pulling the distal fragment. Manual reduction rarely holds. Traction splinting (see below) is required for femur fractures.

Traction Splinting for Femur Fractures

A traction splint applies continuous mechanical traction to maintain reduction. Simple versions can be fabricated.

Thomas splint improvisation:

1. A rigid rod (wood or metal) long enough to extend from groin to 30 cm beyond the foot
2. A padded ring or fork at the groin end that rests against the ischial tuberosity (sit bone)
3. The ankle is tied to the distal end with cloth padding
4. Traction is applied by tensioning the ankle tie against the fixed groin ring
5. Side straps hold the limb to the rod

This device applies 5-10 kg of continuous traction, overcoming thigh muscle spasm and maintaining femur alignment. A femur fracture immobilized in traction for 8-12 weeks (the duration needed for union) can heal without surgery.

Immobilization

See the cast-making article for detailed splinting and casting techniques. Key points for fracture immobilization:

• Always immobilize one joint above and one below the fracture
• Achieve correct alignment before casting
• Check neurovascular status before and after cast application
• Use splints (not circumferential casts) for the first 48-72 hours of acute injury when swelling is maximal

Healing Times by Location

Fracture Location	Typical Union Time
Distal radius (wrist)	6-8 weeks
Radius/ulna (forearm)	6-8 weeks
Humerus (upper arm)	6-10 weeks
Clavicle (collarbone)	6-8 weeks
Rib	3-6 weeks (pain-guided)
Femur (thigh)	12-20 weeks
Tibia (shin)	10-16 weeks
Ankle	6-8 weeks
Metatarsals (foot)	4-6 weeks
Phalanges (fingers/toes)	3-4 weeks
Vertebra (stable)	8-12 weeks

These are minimum times for bony union. Full remodeling and strength return takes 2-3x longer.

Delayed union: if the fracture is not clinically healed (still tender, still unstable) at 1.5x the expected time, reassess: Is alignment maintained? Is the patient malnourished? Is there infection? Address the cause.

Non-union: failure to heal after 2x expected time. Causes: inadequate immobilization, severe displacement, infection, malnutrition, excessive motion. Extremely difficult to treat without surgery.

Rehabilitation

After cast removal:

1. Days 1-7: gentle active movement within comfort range — do not force
2. Weeks 1-2: progressive exercises, walking for lower limb injuries
3. Weeks 2-6: return to full range of motion exercises, strengthening
4. Weeks 6-12: return to full activity

Expect: stiffness, weakness, and wasted muscle. These are temporary. The periosteum (bone covering) is highly pain-sensitive during early rehab — pain during exercise is normal and does not indicate reinjury unless it is sudden and severe.

Adequate nutrition during healing (especially protein and calcium) significantly reduces healing time. A malnourished patient with a fracture heals slowly — prioritize nutrition alongside immobilization.