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A closed fracture is defined as a break in the continuity of the bone which does not communicate with the outside of the body. Management of the patient includes a thorough assessment of the fracture, evaluation of other injuries, and reduction as indicated. The patient is carefully observed for complications should problems arise.
Thirty-one closed fractures of the lower extremity in diabetics were retrospectively reviewed to determine healing times. There was a prolonged union time overall (163% of expected) and in both insulin and oral hypoglycemic-controlled diabetics (157% and 176% of expected). Displaced fractures showed a prolonged union time, while nondisplaced fractures healed in the normal time period (187% and 96% of expected). Fractures treated by open reduction had a more prolonged healing time than those treated by closed reduction (186% and 142% of expected), but this was primarily related to displacement. Sex and age had no effect on union time. The known effects of diabetes mellitus on bone and mineral metabolism in both experimental animals and humans may explain these prolonged union times.
Osteomyelitis developed at closed fracture sites in two children. The infection responded to antibiotic therapy, and the fractures healed without chronic infection developing, impairment of bone growth, or loss of function. It is rare for a closed fracture to develop acute hematogenous osteomyelitis, but the diagnosis should be considered in a child with a closed fracture in whom a fever develops or who complains of increasing pain after the fracture has been reduced and immobilized. In children, the condition has an excellent prognosis.
Acute osteomyelitis following a closed fracture is very rare. A case following a closed epiphyseal (type II) injury of the distal end of the radius is reported and the role of injury as a contributing factor in acute haematogenous osteomyelitis is discussed.
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We present the outcome of non-operative management of fractures of the shaft of the femur in children. Thirty children with non-operatively managed unilateral fractures of the shaft of the femur were studied. The mean age was 6.5 years (range: 1.2 to 12). Axial, angular and rotational malunion were assessed clinically and radiologically by plain films and computed tomography (CT). All children had shortening of the fractured limb with a mean shortening of 1.8 cm (range: 0.5 to 3.5). A significant level of shortening was seen in children over 7 years. In the sagittal plane, all had anterior angulation ranging from 4 degrees to 31 degrees (mean: 17.8 degrees) and in the coronal plane, lateral angulation (varus) was seen in 90% (27 patients) with a mean angle of 8.9 degrees. Rotational malunion ranged from -43 degrees to +43 degrees (mean: 9.5 degrees), 30% had rotational malunion of > 20 degrees compared to the uninjured side; 73% had internal rotation malunion and 27% had external rotation malunion. We conclude that non-operative management of fractures of the shaft of the femur in children often results in malunion at the fracture, particularly in the older age group and in comminuted fractures. Perhaps a longer follow-up might have shown lower levels of malunion. Frequent monitoring of fracture position may reduce the occurrence of deformity. It may be appropriate to consider reduction and operative stabilisation of such fractures whenever neces-
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The principles of treatment of bone fractures in children differ from those in adults and are determined by the morphofunctional features of the growing and developing child organism: the anatomo-physiological peculiarities of the structure and blood supply of the bone of a child, the high regenerative possibilities, the capability for self-correction of some types of residual displacement during growth. Peculiar types of bone injuries occur in childhood which are not encountered in adults. These are subperiosteal linear and folded fractures, fractures of the green stick type, damage to the growth zones (epiphyseolysis and osteo-epiphyseolysis), etc. The localization of the fracture and the size (degree) of displacement of the fragments are very important in the choice of the therapeutic tactics. Predominantly qualitative appraisal of the displacement suffices in metaphyseal and diaphyseal fracture and in injury to the growth zones (extra-articular fracture). Quantitative appraisal of the size of the displacement is advisable in intra-articular fractures, for which the techniques are suggested. Four degrees of fragment displacement are distinguished. Depending on the localization and character of the fracture and the size of the displacement of the fragments, conservative, active surgical, and operative therapeutic tactics may be chosen according to strictly differentiated indications. Each of them includes various methods of fracture management.
Closed fractures may be complicated by associated peripheral nerve injury. However, because clinical information is limited, determining the best course of treatment is difficult. Most patients with closed fractures have a local nerve injury without nerve division; their prognosis for recovery is favorable. In the acute setting, immediate surgery is usually unwarranted because of the difficulty in accurately defining the severity and extent of nerve injury. When débridement of an open fracture or repair is not required, peripheral nerve injuries are best observed and the extremity treated with splinting and exercise to prevent loss of joint motion. Patients who fail to demonstrate signs of recovery at 6 months, either clinically or with electrodiagnostic testing, should undergo exploration to maximize the likelihood for return of function. When, during exploration, the nerve is in continuity, intraoperative measurement of nerve action potentials should be done. Measuring nerve action potentials will determine whether nerve grafting, local neurolysis, or excision of the injured segment, accompanied by primary repair, is the most appropriate treatment.
A rat model for the study of closed fracture healing is described. Standard closed tibial fractures were produced with specially designed pliers in 24 rats. All fractures were located in the middle third of the tibia and healed without complications as delayed union, infection or soft tissue problems. The average angle of the fracture line with the axis of the tibia on lateral view was 80 +/- 2 degrees (SEM). The model is considered to be suited for the study of closed fracture healing processes. Closed intramedullary fracture fixation, can also be evaluated in this model.
OBJECTIVE: Comparison of the healing process in open osteotomy and closed fracture models that were used to study fracture healing. DESIGN: Randomized, prospective study in experimental animals, with a recovery duration of two and four weeks. SETTING: Unrestricted cage activity with weight bearing as tolerated. ANIMALS: Thirty-four skeletally mature, female New Zealand White rabbits. INTERVENTIONS: Closed fractures and open osteotomies of the tibial diaphysis were reduced and immobilized with four-pin, double-bar external fixators. MAIN OUTCOME MEASUREMENTS: Callus circumference was measured with a tape measure, bridging callus was assessed on biplane radiographs and evaluated histologically, and torsional stiffness and maximum torque were measured. RESULTS: Periosteum damage was more severe and hematoma formation was smaller in the osteotomy model, resulting in a delay in biological healing and restoration of the biomechanical properties. CONCLUSIONS: Investigators should consider the difference between the closed fracture and open osteotomy models when selecting an animal model to investigate fracture healing.
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