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GENERAL
INFORMATION ON FRACTURES
When an indirect or
direct force is applied to a bone, there can be a disruption in the
bone’s continuity, causing a fracture, or “broken bone”. When a
fracture occurs, usually the disruption of the bone’s continuity is
obvious, and this can take on several patterns or fracture types.
Examples of these fracture types are shown below. If the disruption
is not obvious but microscopic, it is called a stress fracture. A
stress fracture usually results from a repetitive use injury, such
as with long-distance runners.
Acute fractures usually
present with a known injury and with one or more of the following
signs or symptoms: swelling and/ or bruising, pain that is
increased with movement causing decreased function, and possibly
deformity. Stress fractures tend to cause nagging pains, mild
swelling, and tenderness to touch in an area that is has become
weakened, and this may or may not lead up to a specific time where
the your function is noticeably affected.
Diagnosis of all
fractures involves a careful history and physical examination. The
severity of the fracture is assessed by evaluating the surrounding
skin, the stability of joints in the area, and the function of the
nerves and blood vessels of the affected limb. X-rays will help
determine more specifically how the bone has been disrupted. Some
fractures are difficult to see on x-ray right away and may require
further x-rays days later to look for bone healing as evidence that
a fracture process is present. Other tests such as
CT or MRI may be
ordered if a fracture is suspected but is not obvious on a regular
x-ray. General ways that are used to describe the way a bone has
been broken include reference to one or more of the following:
-
What bone in the
body is affected
-
Whether or not the
fracture causes the skin to be disrupted (e.g. open vs. closed)
-
Where in the bone
disruption has occurred (e.g. shaft, growth plates)
-
What kind of
pattern or “fracture line” is seen (e.g. intra-articular,
transverse, oblique, spiral, comminuted, segmental, torus,
compression, greenstick, pathologic)
-
What kind of
displacement from the normal alignment is present if any
-
Evidence of
problems healing (e.g. slower than normal, no healing, healing
with deformity)
In addition to the
general terms used to describe fractures, most fractures have
acquired specific classifications and/ or names which may be used by
your physician.
Treatment of fractures
varies considerably with the type and severity of injury, associated
injuries present, and the your medical history. Once the type of
fracture is known, general principles of treatment include:
-
“Reducing” the
fracture if it
is displaced (trying to regain proper alignment) by either closed
(no incision into the skin) or by open methods (surgery).
-
Immobilization,
or maintaining proper alignment while the bones heal back together
by using a splint, cast, or internal fixation device positioned
during surgery
-
Rehabilitation
after healing to regain muscle, motion, and smooth functioning
-
Weight-bearing
and increasing activities
as tolerated will be recommended for your specific fracture by your
physician
The average patient
incurring a common fracture will recover in time to normal
functioning with the proper treatment. However, it is important to
note that recovery depends on severity of the fracture and overall
injury, your individual bone healing, and rehabilitation.
Fractures that tend to
be harder to treat are those that are:
-
Markedly displaced
and where the surrounding soft tissues have been affected
-
Fractures that
involve a joint
-
More complicated
fracture patterns: oblique, comminuted, segmental
-
Certain specific
types of fractures: displaced pelvic fractures, unstable cervical/
lumbar fractures, both-bones fractures of forearm / lower leg
-
Fractures where
there is a poor potential for healing because of a thin outer layer
of bone
Possible complications
of fractures include:
-
Infection in the
bone, particularly with open fractures where bone end is exposed to
outside environment
-
Poor bone healing
including slower than normal healing, inability to heal, or healing
with unacceptable deformity
-
Compromised
function of the nerves or blood vessels as a result of the fracture
-
Stiffness and /or
arthritis later in life, particularly with history of fracture that
is severe and/ or involved the joint
The clavicle is the most
common bone injured overall. Usually a fracture in the clavicle
occurs with a fall on the shoulder or when hit with a heavy object.
The majority of fractures occur in the middle of the clavicle, with
a lesser percentage occurring more towards the shoulder or more
towards the center midline of the body. Rarely these fractures are
open, or thru the skin, exposed to the outside environment.
Patients with clavicle
fractures have pain in the area of the fracture and an obvious
deformity or bump. Often it is difficult to lift the affected side
arm. Other additional injuries must be considered including
separation or dislocation of either ends of the clavicle from the
shoulder or sternum.
Most clavicle fractures
can be treated with the use of a sling and rest of the arm for about
four to six weeks (the average amount of time for any bone to
heal). Rarely, poor healing of the clavicle or the severity of the
fracture merits surgical correction with a metal plate and screws.
Regardless of treatment, it is important to note that because it is
a bony area, a bump will always be present after a clavicle
fracture, although it may decrease substantially over four to five
months after the injury.
Fractures in the upper arm, or humerus, can
occur in anyone, but they are most common in elderly females with
osteoporosis after a slip and fall on an outstretched arm.
Fractures more towards the shoulder (called proximal humerus
fractures) are commonly described in how many “parts” or pieces
the fracture is in and whether or not it involves the head of the
humerus, the ball of the ball-and-socket shoulder joint. Fractures
further down in the middle of the humerus are called mid-shaft
humerus fractures and are described by the typical types of
fracture patterns (see
general information on
fractures,
above).
Fractures of the upper arm cause pain, swelling, and
often a lot of bruising down the entire arm. As with any injury,
motion is often decreased because of the pain. Nerves that run down
from the shoulder to the fingertips and can become damaged (often
only temporarily), disallowing certain movements in the wrist or
hand or giving altered sensation patterns in the upper extremity.
Associated injuries are also possible, such as biceps tendon
rupture, shoulder dislocations, or rotator cuff injuries.
Treatment of humerus fractures varies greatly
depending on the severity of the fracture and the general medical
condition/ rehabilitation goals of the patient. Mid-shaft humerus
fractures are often treated without surgery with immobilization
only, but can require surgery if there is significant displacement.
Proximal humerus fractures are more likely to require surgery with a
smaller degree of displacement and this can be done a variety of
ways. All of the methods will require the use of a sling or a
shoulder immobilizer to be worn during part or all of the healing of
the fracture. Initial signs of nerve damage, if present, often
resolve over the course of six months.
Three bones form the
elbow joint: the upper arm bone (humerus) and two bones in the
forearm (the radius and ulna). An elbow fracture can involve a
fracture of any one of these bones in the elbow region. There are
three main types of elbow fractures that occur:
supracondylar (distal humerus) fractures, olecranon fractures, and
radial head fractures.
As with any fracture,
there is often pain, swelling and bruising, and decreased motion
depending on where the fracture is located. A crackling noise
called crepitus might be noticed with motion, especially with distal
humerus fractures. Olecranon fractures might cause numbness in some
of the fingers as swelling in the area presses on the ulnar nerve.
There might be pain with rotating the wrist right and left in a
screwdriver motion with radial head fractures.
With any of the elbow
fracture types, if the bone is merely broken but not out of place,
immobilization with a splint or cast may be the only recommended
treatment, with periodic x-rays to assure the maintenance of proper
alignment and good healing. Surgery is recommended when the
fracture is out of place and loss of function is a concern. Surgery
usually involves opening the joint and fixing the fracture with any
combination of wires, plates, and screws. A similar course of
immobilization is required after surgery to allow the bones to
continue to heal in the correct place.
WRIST
FRACTURES
The most frequently
broken bone in adults occurs in the wrist. Usually the
mechanism of injury involves a fall while the hand is outstretched
to brace the fall. The wrist can break (fracture) in several
different places.
Patients with fractures
in the wrist usually remember a time where an injury occurred,
rather than a gradual increase in pain symptoms. In addition, there
may be acute tenderness, swelling, and possibly bruising around the
wrist. Often movement of the wrist is limited because of pain.
Your physician may check to make sure there is still good
circulation and/ or sensation in the hand and fingers, as well as
verify there is no injury to any of the joints above and below the
wrist. X-rays are necessary to determine if a
definite fracture is present and help to determine what kind of
treatment is needed, if any.
Treatment of wrist
fractures depends on if the broken bone(s) are out of place, or
displaced. A certain amount of displacement is acceptable and
will allow the wrist to return to full functioning after it is
healed. In this case, a splint will likely be applied to immobilize
the wrist in good position while the swelling goes down. After
that, a cast will be applied to further immobilize the wrist while
it continues to heal. X-rays will be taken during most appointments
to make sure the fracture continues to be healing in good position.
If the fracture is
displaced at the time your physician sees you, it is unstable and
requires surgery to fixate the bones back in proper alignment. Good
position can be achieved either with manipulation, the use of pins,
or by fixating with metal plates and screws. After surgery, the
same regimen of splinting, casting, and x-rays is required as for
non-surgically treated patients while the bones heal.
The length of time for
immobilization will be determined by your physician and varies
depending on the severity of the fracture and how well it appears to
be healing on x-ray. While your wrist is immobilized, it is
important to continue to move the other joints in your upper
extremity to avoid additional problems of stiffness. Moving the
shoulder, elbow, and fingers on a regular basis throughout the day
will help with this. As with any fracture injury, there is the
possibility of complications such as poor bone healing, lost motion
and/ or strength, or the development of arthritis.
The hands and feet are
made up of several kinds of bones. The small, squarish bones at the
base of the hand near the wrist are called the carpal bones (hand
bones). The feet has similar bones called the tarsals. Other bones
in the hands that make up the knuckles are elongated bones called
the metacarpals (metatarsals in the feet). The fingers and toes are
actually a series of two or three additional elongated bones in
sequence, called the proximal, middle, and distal phalanges. A
finger or toe fracture is when one of these phalange bones is
broken. Below are diagrams of the bones in the hands and feet.
We use our hands and
fingers for a wide variety of functions and similarly, there are a
wide variety of ways we can sustain injuries to them. Many of these
injuries have predictable mechanisms of injury, such as punching,
jamming a finger tip, a crush injury to the bones, or
hyper-extending a finger. Injuries to the feet can be equally
varied. Stubbing a toe, tripping, a direct blow or force to the
foot, or a quick twisting or rotational motion can cause injury. As
with any fracture, pain, swelling and bruising, and possibly the
inability to move one or more fingers or toes can be present with
fractures in the extremities. It is important to ascertain if the
nerves or blood vessels have been hurt in any way during the course
of injury. X-rays are the most helpful in
pin-pointing the fracture location and severity.
In the hands and feet,
different degrees of “angulation” or tilt in the fractured bones are
considered acceptable (depending on what bone is fractured) and are
expected to heal without lost function. In this acceptable range, a
course of immobilization with tape, or in a cast or splint device
can be worn for a period of time while the bones heal. If there is
a significant degree of angulation from normal and this is suspected
to cause decreased function, pain, or predisposition to further
injury, surgery might be recommended. Surgery for fractures in the
hand and feet can involve a variety of techniques including
attempting to re-align the fracture without an incision but under
anesthesia, pinning a bone so it is anatomically straight, or the
use of a screw to hold a chip of a bone in place. For any of these
or other methods, immobilization is still required after surgery to
allow the bones to heal. Any pins placed are usually taken out in
the middle of the course of treatment and continued healing is
monitored by x-ray evaluation. After the fracture is healed,
regaining motion is the first priority, followed by strength and
function. For fractures in the lower extremity, weight-bearing
might be limited for a period of time to allow the fracture to heal
without excess stress.
HIP
FRACTURES
FEMER
FRACTURES
TIBIA/FIBULA FRACTURES
ANKLE FRACTURES
Ankle fractures are common injuries among both adults and youth.
These fractures can be caused by a variety of mechanisms, usually
with some twisting, rotation, or a fall involved. Two thirds of
ankle injuries involve only one side of the joint, while potentially
more unstable fractures are less frequent but do occur. The bones
that make up the ankle joint that can be injured in an ankle
fracture are the fibula and/ or tibia in the lower leg, and the
talus from the foot. A diagram of the ankle joint is shown below:
Ankle fractures are
caused by some kind of trauma and produce acute pain after the
injury. Swelling, tenderness, and some deformity of the ankle are
likely all present. If the fracture is severe or unstable,
circulation, sensation, and/ or function in the foot may be
affected. In the most severe fractures, blisters may be seen as a
result of injury to soft tissue surrounding the fracture site, or
open wounds may be visible.
Suspicion of an ankle
fracture is made with a careful history and physical examination,
but definitive diagnosis of ankle fractures is made with
x-rays. Several “views” of your ankle will be taken to
assess the relationship between all the bones in the ankle joint.
In the case of mild fractures, x-rays may need to be repeated in one
to two weeks time as they might not appear on initial x-rays after
an acute injury. In addition, a CT scan may be
recommended to evaluate complex fractures, or fractures that involve
areas hard to see on regular x-rays, such as on the undersurface in
between the joints.
Treatment of ankle
fractures depends on the severity and stability of the fracture.
Initial management of all fractures includes attempted reduction
(putting fracture back into proper anatomical position) and
immobilization. In the case of fractures that involve only one side
of the joint, are stable, and are not out of place, simple
immobilization by splinting and casting for a period of time is
likely sufficient. For unstable fractures (usually involving
inside, outside, and/ or behind the ankle joint), surgery is
required to put the joint back together in good alignment. Surgery
involves opening the ankle and correcting the fracture with metal
plates and screws. Immobilization follows all surgeries, and the
length of time in a splint or cast will be determined by your
physician depending on what is required to maintain good fixation of
the metal devices and proper healing of the fracture. Similarly,
progression to weight bearing will be determined by your physician.
At all times, swelling and edema of the ankle is a concern and
should be reduced by methods such as icing and elevating the
affected lower extremity.
Complications of ankle
fractures are similar to those of other fractures. Complete
non-healing of ankle fractures is uncommon, but poor healing or
alignment can occur. Soft tissue breakdown or infections are found
in 1-3%, and are more common occurrences in patients over age 50,
alcoholics, or diabetics. Nerve injury resulting in paralysis of
the foot is uncommon with today’s surgical approaches, but
superficial sensation changes might occur. Lost motion can be a
concern if the fracture is particularly severe and difficult to
reduce, or if motion is not regained after being immobilized. The
development of arthritis is a common complication later in life,
especially if the fracture was particularly severe or did not heal
properly.
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