Often when we think about an injury or fracture, we immediately think about surgery being required to repair the problem. The fact is that the majority of fractures commonly seen in orthopedic offices can be treated without surgery. The question then is: "What types of fractures typically will require surgery and what types of fractures can be treated without surgery?" This discussion will deal with the fractures that are most commonly seen in the office, which involve the hand, wrist, and shoulder.

You might think that sustaining a simple fracture as a young person would automatically be more easily treated than treating that same fracture when sustained as senior, however; this is not always the case. Much depends on the location of the fracture as well as the expected activity level of the individual. Consider these three scenarios:

1. A mildly-displaced forearm fracture in a 7-year-old youngster can often be treated with simple cast immobilization because, in the ensuing months after the cast is removed, the bones will continue to remodel. Up until about the age of 15 in females and 16 in males, the bones are constantly undergoing changes or "remodeling" as an individual matures. Oftentimes, an x-ray taken six months after a mildly-angulated fracture in a 7-year-old will show no evidence of a previous fracture and will show that the bone has returned to its normal alignment and shape. A similar fracture involving an adult or someone who is skeletally-mature will behave quite differently. These fractures must be reduced anatomically; or in layman's terms, put back together in exact alignment, without any angulation. The reason for this is that the fracture, once it heals, will not undergo any kind of remodeling process. If an adult angulated forearm fracture was treated by simple cast immobilization, there would be long-term consequences after the fracture healed, such as a deformity in the forearm and lack of full motion of the forearm and the wrist. These outcomes certainly are not acceptable. Thus, an adult who sustains a fracture of the forearm will probably require an operation in which plates are placed over the fracture site, once the fracture has been reduced in the operating room. Likewise, fractures involving the hand and the wrist in skeletally-immature patients are often treated without surgery, but those same injuries might require surgery in an adult.

2. Conversely, a fairly common fracture that occurs in the older population is called a Colles fracture. This is fracture of the distal radius at the wrist. When this fracture is seen in the elderly population, operative intervention probably will not be required. Oftentimes, these fractures can be reduced in the office or the operating room and placed in a cast. Once the fracture heals, the patient will have most of the normal function required for daily activities. However, in a teenager who is approaching skeletal maturity, a similar fracture would probably require operative intervention, since the patient is younger and would have higher expectations for use of the wrist. In addition, after closed reduction (alignment of the bone without surgery), the bone would not remodel adequately to allow the patient to have a normally-functioning wrist.

3. The one area of the body where older patients can often sustain fractures that do not require surgery is the shoulder. Why? Because of the many joints in the body, the shoulder has the largest range of motion. If the articular portion of the shoulder joint is still reasonably aligned, the fracture involves the portion of the shoulder near musculature attachments and is not significantly displaced, most of these fractures can be treated simply by wearing a sling for a few weeks, followed by physical therapy So, for an elderly patient who sustains a fracture that heals reasonably well-aligned, they may lose a few degrees of motion, but are left with enough motion remaining within the joint to accomplish their activities of normal daily living. In a child, a fracture near the growth plate in the shoulder will probably heal without surgery and continue to remodel, resulting in full recovery.

As you can see from the above discussion, every fracture needs to be evaluated by an experienced orthopaedic surgeon. They understand how patient age, fracture location and patient activity levels will impact future bone healing and remodeling. They are also best-qualified to make the determination of when surgical reduction and possible bone structure reinforcement (plates, pins, cages, etc.) may be necessary for optimal bone healing and recovery of the patient.