Fracture surgery
What is Fracture Surgery
Where there is a complete fracture of the arm, the bones are often no longer aligned and need to be put back into the correct position. The bones then have to be held in this position for 6 weeks whilst healing takes place. The bone can be held in several different ways depending on the nature of the fracture.
If you leave a fracture without treatment, you can cause deformities in the hand, wrist, and elbow.
Manipulation Under Anaesthetic
Sometimes, the bone may be too bent and needs to be straightened. This can be done with a short anaesthetic and is called a manipulation under anaesthetic (MUA). Following manipulation, once the bone is back in the correct position, it is placed in a plaster cast.
For children over the age of 6, time in plaster is usually around 3 weeks. Younger children ages 3-4 would need to be in plaster for 2 weeks, and those less than 2 years old for 1 week. Clinical examination is required to asses fracture healing. If the fracture site is still painful after the plaster is removed, an x-ray is taken. If there is suspicion that the fracture has not fully healed the arm is put back in plaster for a further 2 weeks.
There is a higher chance that the bone will move out of position in the plaster, so x-rays are necessary to check the alignment of the bone at 1 and 2 weeks after the manipulation. The bone heals well with normal function at 6 weeks, when children can return to sport.
If the bones cannot be manipulated back into acceptable position; the fracture is too unstable to be held in plaster; or the x-rays show the bones have moved out of position in the plaster, further surgery may be necessary.
K Wires
These can be used in fractures which are near to the wrist. The bones are pushed back into the correct position and held by passing a wire through the skin, then the bone fragment and through to solid bone the other side. The wires are left proud of the skin so they can be removed in the clinic after 4-6 weeks. The wires come out easily and are not painful.
Intra medullary rods
These are flexible rods which pass through the centre of the bone. They are excellent at holding the bone straight and promote quick healing. They can be inserted through small incisions so there is less scarring. Depending on the nature of the fracture, the arm is rested in a plaster for 2-6 weeks. The rods should stay in for at least 3 months before being removed with a second operation.
Plate and screws
These are used if the fracture is towards one end of the bone. An incision is used, and the plate and screws hold the bone rigid and can control small fragments. They allow early movement but can take longer to fully heal. The plates stay in the bone and are not removed. This rarely causes any problems, and removing them is associated with complications, such as nerve injury and re-fracture of the bone.
For children over the age of 6, the time taken for the bone to heal from a complete fracture is usually around 6 weeks. Younger children ages 3-4 would need 4 weeks recovery and those less than 2 years old need 2 weeks. Clinical examination is required to asses fracture healing. X-rays are not routinely taken because new bone does not always show up. If the fracture site is still painful after the plaster is removed, an x-ray is taken. If there is suspicion that the fracture has not fully healed the arm is put back in plaster for a further 2 weeks.
Surgery for metacarpal fractures
This can be done under local anaesthetic / nerve block or general anaesthetic. The fracture is reduced back into the right position and held in place with wires screws or plates depending on the injury and your functional demands. These implants hold the fracture in an acceptable position while it heals. Wires stay in place for 4 weeks other metal work is usually left in position permanently.
What should I expect after Fracture Surgery?
Local anaesthetic will be injected into the wound at the end of the operation. The area will remain numb for around 6 hours. Prior to the anaesthetic wearing off, you should start taking regular pain relief.
Swelling causes discomfort and stiffness which can be made worse by having the arm hanging down by your side. It is therefore recommended to keep the hand elevated above the level of your heart for the first 48 hours. It is also important to mobilise the fingers to ensure a full range of motion to reduce stiffness.
The wound will be checked after 2 weeks. Any wires in place will poke out of the skin and will need to be kept clean and dry until they are removed in clinic after 4 weeks.
What are the risks of Fracture Surgery?
Operations to fix fractures are very successful and most patients are very happy with the results. Fracture surgery is very low risk but can cause the following complications:
- Infection – if your wound becomes very red, hot and swollen, you should contact your GP immediately or visit your nearest A&E department
- Pain – This usually settles during the first week following the procedure and is usually moderate
- Stiffness – The hand or wrist in some cases is very stiff, which can sometimes lead to limited range of motion following the operation
- Swelling – this is normal and the swelling with reduce after a few weeks following the procedure
- Nerve injury – Localised numbness around the wound site may occur. It usually resolves with time
- Non-union – this is a possibility when the bone lacks adequate stability, blood flow, or both
- Failure of the plate and screws – this is very rare. In some patients the plate can be felt under the skin and cause some irritation when resting on a table
When can I return to work after Fracture Surgery?
The hand will be protected by a splint, so any sedentary or office based work that can be done using one hand can be resumed within a few days, as long as you are comfortable. The hand will however need to be kept elevated in a sling.
If you are a manual worker with heavy duties, you should stay off work for around 8 weeks. This will however vary depending on your profession, the type of fracture and how well it has healed on x-ray. Your surgeon will discuss this with you in depth in clinic.
When can I return to driving after Fracture Surgery?
Driving will depend on the location of the fracture and the time required for it to heal. You should discuss this with your surgeon.
The One Team Specialists
Anthony Hearnden
Consultant Orthopaedic Surgeon FRCS (Tr&Orth), Shoulder, Elbow, Hand and Wrist
