When a person breaks a bone, one of the first questions that often gets asked is whether or not surgery is required. Many people associate a broken bone with the need for surgery, but that is not always the case. In certain circumstances, even when surgery would help restore the alignment and give stability to the injured region, the patient is not an ideal candidate. Therefore, surgeons must take several things into consideration when determining whether it is more beneficial for someone to undergo surgical correction for their break or have it be treated conservatively.
Below is a list of questions and principles surgeons, specifically podiatrists, often use to help make the best decision between surgery and conservative care for lower extremity fractures.
Which bone is broken?
There are 28 bones in the foot. They vary in size, structure, healing potential, and how much force is placed through them with weight-bearing; therefore, not each bone is treated the same when it breaks.
For example, the toe bones are rarely surgically fixed. Most often, they are treated conservatively with buddy taping and a stiff-soled surgical shoe. The bones behind them, called the metatarsal bones, play a more important role to the foot, though. The heads of the metatarsals make up the ball of the foot, which bears a significant amount of weight when standing and participating in other weight-bearing, especially high impact, activities. So, when they break, a more in-depth evaluation is often performed to determine whether or not the metatarsal(s) should be surgically fixed.
Displacement, Shortening, & Angulation
Sometimes there is a break in the bone without any movement or shifting of the bony fragments (e.g. stress fractures). Because the two broken ends are still touching, and their alignment has not changed, surgery is usually not required.
When the bones shift, shorten, or become severely angulated, though, complications can result, including altered gait, foot deformities, and arthritis. Therefore, there are general guidelines surgeons follow when determining the need for surgery to restore alignment and minimize the risk of such complications, some of which may be done through closed reduction (resetting of the bones without creating an incision).
Displacement: If there is a step-off of greater than 2-mm between the outer edges of the bone, surgical correction is considered to improve the alignment (see left picture below).
Shortening: Like displacement, the 2-mm rule applies. This is especially important when evaluating metatarsal fractures because if there is significant shortening, it can affect the overall metatarsal parabola and how much weight gets dispersed amongst the adjacent metatarsal heads when standing (see middle picture below).
Angulation & Rotation: When the distal bony fragment becomes angulated and/or rotates, this can also affect weight-distribution, as well as cause obvious foot deformities. When the angulation of the deformity is greater than 10°, surgery is often considered (1) (see right picture below).
The more stable the fracture is, the more likely it can be treated conservatively with immobilization and weight-bearing restrictions. As the break becomes more unstable, though, surgical fixation is necessary to restore alignment and improve the stability. Such examples of unstable fractures are a bimalleolar ankle fracture (both sides of the ankle are broken) and a comminuted (3 or more pieces), displaced metatarsal fracture (see picture at right).
Intra-articular (Joint) vs Extra-articular (Outside Joint) Fracture
If the fracture goes through the joint (aka intra-articular fracture), the joint cartilage, or cushion, becomes disrupted, leading to eventual arthritis of the joint. Therefore, it is very important to keep the joint surfaces as smooth and anatomically aligned as possible. If there is significant displacement, angulation, or damage at the joint level, surgery will likely be necessary and may even include fusing the joint primarily to avoid a second surgery down the road. If there is no displacement, the fracture may be able to be treated conservatively, but the patient must be informed that painful arthritic symptoms may still arise in the future.
Health status of the patient
The health status of a patient can throw a kink in any of the above-mentioned guidelines because not everyone is healthy enough to undergo surgery or has the ability to rehab after surgery and return to their pre-injury level. Others may be at increased risk of postoperative complications because they have poor healing potential as a result of diminished bone density, poor circulation, or significantly elevated blood sugar levels (i.e. diabetes). For these people, it is crucial to thoroughly evaluate the risks and benefits of doing surgery versus treating them conservatively. Regardless of the decision, close follow-up is important in case a change in the treatment plan is necessary.
An open fracture is one in which there is an associated break in the skin, thus exposing the bone. These fractures are considered a surgical emergency because if they are not treated promptly and appropriately, they can result in severe complications, including bone infections and amputations.
All open fractures need to be flushed and cleaned out and the patient should be placed on antibiotics. The need for fixation, the type used (internal vs external), and when to do it depends on the previously mentioned guidelines for fixation as well as the cleanliness of the wound.
Recovery Time & Recurrence of Injury
Recovery time is not always considered when determining whether a fracture needs to be surgically fixed because, in most cases, if the benefits of surgery outweigh the risks, patients usually understand the importance of a proper recovery; however, there are special circumstances where recovery time is a major player in the decision-making process.
For example, surgery is a popular choice amongst high-leveled athletes, especially professional athletes, because their careers depend on them being healthy. By undergoing surgery, a strong and stable construct is holding their bones together, so theoretically, they should be able to weight-bear and return to activities sooner. Because the hardware is bridging the bony fragments together, they should also have a less chance of breaking that area again.
On the opposite end of the spectrum, elderly patients may often be treated conservatively because the surgical recovery time may be too difficult for them. If they have to be off their lower extremity for two months, they may become too deconditioned and have a harder time returning to their pre-injury level. The goal in their recovery is to treat and protect the broken limb but keep them as functional as possible throughout the process.
There are many things to consider when determining if surgery is the right choice for each person that arrives to the clinic, or emergency department, with a fractured lower extremity. Surgery has its benefits, including restoration of anatomic alignment with a stable construct, potential return to activities sooner, and minimization of future complications associated with malalignment of the bones, including altered gait, foot deformities, and arthritis. Surgery also carries with it potential complications, including the overall risk of undergoing surgery and anesthesia, wound and bone healing complications, and the need for revisional surgery. Therefore, the decision to undergo surgery should not be taken lightly. A thorough conversation should be had between the surgeon and the patient to ensure that the patient can make the most informed decision for him-/herself and the injured extremity.
DISCLAIMER: The above information is meant for educational purposes only and should not be construed as medical advice. Please consult the doctor, or your own healthcare professional, should you have questions or concerns related to your health.
1. Puccinelli, A., Ballinger, C., Green, D., Agan, D. (2016) Central Metatarsal Fractures: A Radiographic Review. The Podiatry Institute, PDF.
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