The periosteum plays a crucial role both in the management of the fracture and in the provision of skin cover. In addition to providing an effective barrier to infection, a significant proportion of the blood supply to the superficial cortex of the bone reaches it through the periosteum.
This explains why avascular necrosis of the superficial cortex and surface sequestration regularly occur where bone is left denuded of periosteum by the injury, and also provides the reason why nothing should be done in manipulating and fixing the fracture which might denude more bone or add to the periosteum already damaged. If plates and screws are being used they should be applied on top of the periosteum even though this may add to the technical problems of fixation.
The surgeon has to accept the therapeutic problems posed by the cortical bone denuded by the injury, but he should not add to them by surgically stripping periosteum.
In relation to the role of the periosteum in the
provision of skin cover, cortical bone which is covered with periosteum will accept a split skin graft; cortical bone denuded of periosteum cannot be expected to accept a split skin graft.