Improved fracture management: open reduction and internal fixation During the past few decades, there have been significant advances in the way orthopaedists treat fractures. Consequently, fractures are now healing more dependably and with less residual deformity than ever before. Patients treated for orthopaedic trauma are more likely to subsequently lead normal lives without significant disability.

One of the initial accomplishments of the AO was the conception of 4 treatment principles that are still valid today. The first principle stresses the importance of obtaining an anatomical reduction of the fracture fragments, especially when the fracture extends into the joint. If closed methods of reduction prove inadequate, open reduction of the fragments by surgical means is carried out. Anatomic reduction is desired to prevent the development of posttraumatic arthrosis and to improve the chances of having a long-lasting and fully functional joint.

The second principle is an extension of the first. After obtaining a good reduction of the fracture fragments, it is necessary to achieve stable fixation of the fragments to maintain the proper anatomic shape. This can be accomplished by a variety of methods ranging from external splints, such as plaster fixation, to internal fixation by plates, screws, wires, and intramedullary nails. Also included are transcutaneous splints—the so-called external fixators. Success of the modern fixation techniques over the past several decades has spawned substantial interest by equipment and instrument manufacturers to develop fracture stabilization equipment.

The third principle is an important concept that has been increasingly recognized as a critical element for proper fracture healing. The preservation of the blood supply to the bone fragments and the soft tissue by means of atraumatic surgical techniques is vital in maintaining adequate nutrition to the fragments and preventing bone necrosis. Understanding of this simple concept is due in large part to the greater efforts of basic science researchers directed at the study of osteosynthesis.

The fourth principle, early and pain-free mobilization, emphasizes the desire for early postoperative motion of the muscles and joints adjacent to the fracture. This concept was contrary to the opinion of the time—that prolonged immobilization was necessary for proper fracture healing to occur. The primary reason for advocating early, protected mobilization is that early motion prevents many of the undesirable sequelae that had, at that time, been accepted as unavoidable with the treatment of fractures. Problems, such as stiff joints, marked muscle atrophy, and osteoporosis, were common following immobilization, and more troublesome complications, such as pneumonia, decubitus ulceration, and deep vein thrombosis, were due in large part to prolonged recumbency. The move from an era in which prolonged immobilization was the mainstay of treatment to today’s emphasis on early motion and rehabilitation has improved, without compromise, fracture healing and posttraumatic musculoskeletal function.