What causes a fracture?

Fractures occur when bone cannot withstand outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been lost and the bone structure fails.

Broken bones hurt for a variety of reasons including:

• The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the bone is broken or bruised.
• Broken bones bleed, and the blood and associated swelling (edema) causes pain.
• Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms cause further pain.

 Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important to provide a history of the injury to decide what potential problems might exist. Moreover, fractures don’t always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the bone may determine what type of injury that occurs. Descriptions of fractures can be confusing. They are based on:

• where in the bone the break has occurred,
• how the bone fragments are aligned, and
• whether any complications exist.

The first step in describing a fracture is whether it is open or closed. If the skin over the break is disrupted, then an open fracture exists. If the skin’s integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively.

Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

Finally, the fracture’s alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren’t in the right place, they need to be reduced or placed back into their normal alignment.

How is a fracture diagnosed?

When you arrive for medical care, the doctor will take a history of the injury. Where, when, and why did the injury occur? Did the person trip and fall, or did they pass out before the fall? Are there other injuries that take precedence over the fracture? For example, a person who falls and hurts their wrist because they had a stroke or heart attack will have their fracture care delayed to allow care for the life threatening illness. The injured area will be examined and a search will happen for potential associated injuries. These include damage to skin, arteries and nerves.

Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the doctor believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an injection into the muscle. This allows the stomach to remain empty for potential anesthesia.

A decision will be made whether x-rays are required, and which type of x-ray should be taken to make the diagnosis and better assess the injury. There are guidelines in place to help doctors decide if an x-ray is necessary. Some include the Ottawa ankle and knee x-ray rules.

The body is three dimensional, and plain film x-rays are only two dimensional. Therefore, two or three x-rays of the injured areas may be taken in different positions and planes to give a true picture of the injury. Sometimes the fracture will not be seen in one position, but is easily seen in another.

There are areas of the body where one bone fracture is associated with another fracture at a more distant part. For example, the bones of the forearm make a circle and it is difficult to break just one bone in that circle. Think of trying to break a pretzel in just one place, it is difficult to do. Therefore broken bones at the wrist may be associated with an elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The doctor may x-ray areas of the body that don’t initially appear to be injured.

Occasionally, the broken bone isn’t easily seen, but there may be other signs that a fracture exists. In elbow injuries, fluid seen in the joint on x-ray is an indicator of a subtle fracture. And in wrist injuries, fractures of the scaphoid or navicular bone may not show up on x- ray for one to two weeks, and diagnosis is made solely on physical examination with swelling and tenderness over the snuffbox at the base of the thumb.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the neck and back, many times, first responders or paramedics may choose to place the injured person on a long board and in a neck collar to protect the spinal cord from potential injury.

Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial splint does not go completely around the limb. After a few days, the splint is removed and replaced by a circumferential cast. Circumferential casting does not occur initially because fractures swell (edema). This swelling would cause a build up of pressure under the cast, yielding increased pain and the potential for damage to the tissues under the cast.

Surgery

Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the orthopedic surgeon believes that the break is at risk (for staying where it is) once the bone fragments have been aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and require surgery.

Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are temporary until the healing of the bone is complete and surgically removed at a later time.