Overview of Fractures

Many fractures cause noticeable bleeding around the injury. Rarely, bleeding within the body (internal bleeding) or from an open wound (external bleeding) is massive enough to cause a life-threatening drop in blood pressure (shock). For example, shock may result when fractures of the thighbone (femur) or pelvis cause severe internal bleeding. If a person is taking a drug to prevent blood clots from forming (an anticoagulant), relatively minor injuries can cause substantial bleeding.

A dislocated hip or knee can disrupt blood flow to the leg. Thus, the tissues in the leg may not get enough blood (called ischemia) and may die (called necrosis). If enough tissue dies, part of the leg may have to be amputated. Sometimes fractures of the elbow or upper arm can disrupt blood flow to the forearm, causing similar problems. A disrupted blood supply may not cause any symptoms until several hours after the injury.

Sometimes nerves are stretched, bruised, or crushed when a bone is fractured. A direct blow can bruise or crush a nerve. These injuries usually heal on their own over weeks to months to years, depending on the severity of the injury. Some nerve injuries never heal completely.

Rarely, nerves are torn, sometimes by sharp bone fragments. Nerves are more likely to be torn when the skin is torn. Torn nerves do not heal on their own and may have to be repaired surgically.

Pulmonary embolism is the most common severe complication of serious fractures of the hip or pelvis. It occurs when a blood clot forms in a vein, breaks off (becoming an embolus), travels to a lung, and blocks an artery there. As a result, the body may not get enough oxygen.

Having a hip fracture greatly increases the risk of pulmonary embolism because it involves

• Injury to the leg, where most of the clots that cause pulmonary embolism form

• Forced immobility (having to stay in bed) for hours or days, slowing blood flow and thus giving clots the opportunity to form

• Swelling around the fracture, which also slows blood flow in the veins

About one third of people who die after a hip fracture die of pulmonary embolism. Pulmonary embolism is much less common when the lower leg is broken and is very rare when the arm is broken.

Fat embolism rarely occurs. It can occur when long bones (such as the thighbone) are fractured and release fat from the bone's interior (marrow). The fat may travel through the veins, lodge in the lungs, and block a blood vessel there, causing pulmonary embolism. As a result, the body does not get enough oxygen, and people may become short of breath and have chest pain. Their breathing may become rapid and shallow, and their skin may become mottled or blue.

Rarely, compartment syndrome develops. For example, it may develop when injured muscles swell a lot after an arm or a leg is broken. Because the swelling puts pressure on nearby blood vessels, blood flow to the injured limb is reduced or blocked. As a result, tissues in the limb may be damaged or die, and the limb may have to be amputated. Without prompt treatment, the syndrome can be fatal. Compartment syndrome is more likely to occur in people who have certain fractures of the lower leg, certain arm fractures, or a Lisfranc fracture (a type of foot fracture).

If the skin is torn when a bone is broken, the wound may become infected, and the infection may spread to the bone (called osteomyelitis, which is very difficult to cure).

Fractures that extend into a joint usually damage the cartilage at the ends of bones in the joint (called joint surfaces). Normally, this smooth, tough, protective tissue enables joints to move smoothly. Damaged cartilage tends to scar, causing osteoarthritis, which makes joints stiff and limits their range of motion. The knee, elbow, and shoulder are particularly likely to become stiff after an injury, especially in older people.

Physical therapy is usually needed to prevent stiffness and help the joint move as normally as possible. Surgery is often needed to repair the damaged cartilage. After such surgery, the cartilage is less likely to scar, and if scarring occurs, it tends to be less severe.

Some fractures can make a joint unstable, increasing the risk of repeated injuries and osteoarthritis. Appropriate treatment, often including a cast or splint, can help prevent permanent problems.

In children, if a growth plate in a leg is fractured, the affected leg may not grow normally and may be shorter than the other leg. Growth plates, which are made of cartilage, enable bones to lengthen until children reach their full height. If a fracture does not involve the growth plate, it may stimulate bone growth from the fracture site itself. If it stimulates growth, the fractured leg may grow too much and be longer than the other leg.

In adults, surgery to repair the thighbone may result in one leg that is longer than the other.

Sometimes broken bones do not grow back together as expected. They may

• Not grow back together (called nonunion)

• Grow back together very slowly (called delayed union)

• Grow back in the wrong position (called malunion)

These problems are more likely to occur when

• The broken bones are not kept next to each other and are not kept from moving (meaning they are not immobilized with a cast or a splint).

• The blood supply is disrupted.

Certain disorders, such as diabetes and peripheral vascular disease, and certain drugs, such as corticosteroids, can delay or interfere with healing.

When blood flow to a bone is disrupted, part of the bone may die, resulting in osteonecrosis. Certain injuries (such as scaphoid wrist fractures and hip fractures in which the broken bones are out of place) are more likely to cause osteonecrosis.

Doctors ask the person (or a witness) to describe what happened. Often, the person does not remember how an injury occurred or cannot describe it accurately. Knowing how the injury occurred can help doctors determine the type of injury. For example, if a person reports that a snap or pop occurred, the cause may be a fracture (or an injury to a ligament or tendon). Also, doctors ask in which direction the joint was stressed during the injury. This information can help doctors determine which bones and other structures are damaged.

Doctors also ask when the pain started and how severe it is:

• If it started immediately after the injury, the cause may be a fracture or a severe sprain.

• If the pain began hours to days later, the injury is usually minor.

• If the pain is more severe than expected for the injury or if the pain steadily worsens during the first hours after the injury, compartment syndrome may have developed or blood flow may be disrupted.

The physical examination includes the following (in order of priority):

• Checking for damage to blood vessels near the injured body part—for example, by checking pulse and skin temperature and color

• Checking for damage to nerves (for example, checking sensation) near the injured part

• Examining and moving the injured part

• Examining the joints above and below the injured part

Doctors gently feel the injured part to determine whether bones are in pieces or out of place and whether the area is tender. Doctors also check for swelling and bruising. If no swelling develops within several hours after the injury, a fracture is unlikely.

Doctors also ask whether the person can use, put weight on, and move the injured part.

Doctors test the stability of a joint by gently moving it, but if a fracture is possible, x-rays are done first to determine whether moving the joint is safe. Doctors check for grating or crackling sounds (crepitus) when the injured part is moved. These sounds may indicate a fracture.

Doctors also check the joint above and below the injured joint and check for ligament, tendon, and muscle injuries.

If pain or muscle spasms interfere with the examination, the person may be given a pain reliever and/or muscle relaxant by mouth or injection, or a local anesthetic may be injected into the injured area. Or the injured part may be immobilized until the spasms stop, usually for a few days, and then examined.

Imaging tests used to diagnosis fractures include

• X-rays

• Magnetic resonance imaging (MRI)

• Computed tomography (CT)

X-rays are the most important and usually the first and only test done to diagnose a fracture.

However, x-rays are not always needed, depending on which body part is affected and what doctors suspect. For example, if an injured body part (such as the toes, except the big toe) would be treated the same way regardless of whether it is fractured, x-rays are usually not needed.

X-rays are usually taken from at least two angles to show how the fragments of bone are aligned. These routine x-rays may not show small fractures when the pieces of broken bone remain in place (that is, they do not separate into fragments). Such fractures are called occult (hidden) fractures. So sometimes additional x-rays are taken from different angles. Occasionally, doctors wait to take x-rays for a few days or even weeks because some occult fractures, such as rib fractures, stress fractures, and scaphoid wrist fractures, become visible on x-rays only after the fracture begins to heal and calcium is deposited in the new bone.

When x-rays do not show a fracture, but doctors still suspect one, doctors may apply a splint and re-examine the person days later. If symptoms are still bothersome, they may take another x-ray. Fractures may be easier to see on x-rays after they have been healing for a while.

If x-rays show a fracture in a bone that looks abnormal (for example, if areas of bone look unusually thin), the fracture probably occurred because a disease (such as osteoporosis) weakened the bone.

CT or MRI may be done when

• Results of the examination strongly suggest a fracture but x-rays do not show one.

• A specialist needs more detailed views of the fracture to determine the best way to treat it.

CT and MRI may also be done to provide more detail about fractures than routine x-rays can show. CT can show the fine details of a fractured joint surface and areas of a fracture that are covered by undamaged bone. CT and particularly MRI can show soft tissues, which are not usually visible on x-rays. MRI shows the tissues around the bone and thus helps detect injury to nearby tendons, ligaments, cartilage, and muscle. It can show changes caused by cancer. MRI also shows injury (swelling or bruising) within the bone and can thus detect small fractures before they appear on x-rays.

Other tests may be done to check for related injuries:

• Angiography (x-rays or CT scans taken after a contrast agent, which can be seen on x-rays, is injected into arteries) to check for damaged blood vessels

• Nerve conduction studies to check for damaged nerves

Imaging tests enable doctors to identify the type of fracture and describe it precisely.

Some Types of Fractures

Fractures in children are often treated differently from those in adults because the bones in children are smaller, more flexible, less brittle, and still growing. Children’s fractures heal much faster and more perfectly than adult fractures do. Several years after most fractures in children, the bone can look almost normal on x-ray.

For children, doctors often prefer treatment with casts over surgery because

• Children have less stiffness after wearing a cast than adults do.

• They are more likely to be able to move normally after being in a cast.

• Surgery near a joint can damage the part of the bone that enables children to grow (the growth plate).

In the emergency department, doctors check for injuries that require immediate treatment.

If the skin is torn, the wound is cleaned, usually after a local anesthetic is used to numb the area, and covered with a sterile dressing. Also, the injured person is given a vaccine to prevent tetanus and antibiotics to prevent infection.

To make sure the injured part is not deprived of blood, doctors surgically repair damaged arteries unless the arteries are small and blood flow is not affected.

Severed nerves are also repaired surgically, but this surgery can be delayed until several days after the injury if necessary. If nerves are bruised or damaged, they may heal on their own.

nonsteroidal anti-inflammatory drugs (NSAIDs) are sometimes not recommended due to the risk of bleeding. However, if no operation is planned, NSAIDs can be used.

PRICE refers to the combination of

• Protection

• Rest

• Ice

• Compression (pressure)

• Elevation

If people who have a fracture also have soft-tissue injuries, they may benefit from PRICE. PRICE is used to treat injured muscles, ligaments, and tendons.

Protection helps prevent further injury that could worsen the original one. It may involve limiting the use of the injured part, avoiding putting weight on the injured body part, using crutches, and/or wearing a splint or cast.

Rest prevents further injury and may speed healing.

Ice and compression minimize swelling and pain. Ice is enclosed in a plastic bag, towel, or cloth and applied for 15 to 20 minutes at a time, as often as possible during the first 24 to 48 hours. Usually, compression is applied to the injury with an elastic bandage.

Elevating the injured limb helps drain fluid away from the injury and thus reduces swelling. The injured limb is elevated above heart level for the first 2 days.

After 48 hours, people can periodically apply heat (for example, with a heating pad) for 15 to 20 minutes at a time. Heat may relieve pain. However, whether heat or ice is best is unclear, and what works best may vary from one person to another.

How To Fit and Use Crutches

Often, broken bones must be moved back into their normal position (realigned, or reduced). For example, reduction is usually necessary if

• Pieces of a broken bone have become separated.

• Pieces of a broken bone are out of alignment.

Certain fractures in children do not need to be realigned because the bone, which is still growing, can correct itself.

If possible, reduction is done without surgery (called closed reduction), by manipulating the bones or bone fragments back into place. After reduction is done, doctors usually take x-rays to determine whether the fractured bones are in their normal position.

Some injuries must be realigned surgically (called open reduction).

Because reduction is usually painful, people are usually given pain relievers, sedatives, and/or an anesthetic before the procedure. The types of drugs that are used depend on how severe the injury is and how reduction is to be done:

• Open reduction: People are given a general anesthetic by injection or through a face mask, making them unconscious. This procedure is usually done in an operating room.

After being realigned, the injury must be kept from moving (be immobilized).

Casts, splints, or slings are usually used after closed reduction of a fracture.

Hardware devices, such as pins, screws, rods, and plates, are often used during open reduction of a fracture. This procedure is called open reduction and internal fixation (ORIF).

Immobilization reduces pain and helps with healing by preventing further injury to surrounding tissues. If a leg or an arm bone is fractured, immobilization may help prevent fat embolism. Immobilization is helpful for most moderate or severe fractures. Joints on both sides of the fracture are immobilized.

If immobilization lasts too long (for example, for more than a few weeks in young adults), the joint may become stiff, sometimes permanently, and muscles may shorten (causing contractures) or shrink (waste away, or atrophy). Blood clots may develop. Such problems can develop quickly, and contractures can become permanent, usually in older people. Consequently, doctors encourage movement as soon as the fracture heals. They also tend to use treatments that enable older people to walk as soon as possible (such as surgical repair of a hip fracture), rather than ones that require them to be immobilized for a long time (such as bed rest or a cast).

Physical therapists can advise people about what they can do while their injured part is immobilized to maintain as much strength, range of motion, and function as possible. After immobilization has ended, physical therapists can help people with exercises to strengthen and stabilize the injured part. These exercises can help prevent future injuries and impairment.

Whether immobilization is required and which technique is used depend on the type of fracture.

Most fractures are immobilized with a cast, splint, or sling until they heal. Without immobilization, the broken ends are likely to move, healing is slower, and the bones may not grow back together. If the broken bones have been separated or are out of alignment, they usually must be realigned (reduced) before being immobilized.

Casts are usually used for injuries that must be kept immobilized for weeks.

Commercial Cast Cover

Image

Image courtesy of Danielle Campagne, MD.

To apply a cast, doctors wrap the injured part in cloth, then apply a layer of soft cottony material to protect the skin from pressure and rubbing. Over this padding, doctors wrap dampened plaster-filled cotton bandages or fiberglass strips, which harden when they dry. Plaster is often used to immobilize broken bones that have been separated because it molds well and is less likely to rub against the body. Fiberglass casts are stronger, lighter, and longer-lasting. After a week or so, the swelling goes down. Then, the plaster cast can sometimes be replaced with a fiberglass cast to fit the limb more snugly.

People who require a cast are given special instructions for its care. If a cast is not correctly cared for, problems can develop. For example, if the cast becomes wet, the protective padding under the cast may become wet, and drying it completely may be impossible. As a result, the skin can soften and break down, and sores may form. Also, if a plaster cast gets wet, it can fall apart and thus no longer protect and immobilize the injured area.

People are instructed to keep the cast elevated as much as possible at or above heart level, especially for the first 24 to 48 hours. They should also regularly flex and extend their fingers or wiggle their toes. These strategies help blood drain from the injured limb and thus prevent swelling.

If the cast causes persistent or worsening pain, feels excessively tight, or causes new numbness or weakness, people must contact a doctor or go to the emergency department immediately. These symptoms may be due to a developing pressure sore or compartment syndrome. In such cases, doctors may have to remove the cast and apply another one.

A splint can be used to immobilize some fractures, particularly if they need to be kept immobile for only a few days or less. Splints allow people to apply ice.

A splint is a long, narrow slab of plaster, fiberglass, or aluminum applied with elastic wrap or tape. Because the slab does not completely encircle the limb, there is room for some expansion in case the injured area swells. Thus, a splint does not increase the risk of developing compartment syndrome. Some injuries that eventually require a cast are first immobilized with a splint until most of the swelling resolves.

For finger fractures, aluminum splints lined with foam are commonly used.

A sling by itself can provide sufficient support and comfort for many shoulder and elbow fractures. The weight of the arm pulling downward helps keep many shoulder fractures aligned. Slings can be useful when complete immobilization has undesirable effects. For example, if a shoulder is completely immobilized, the tissues around the joint may become stiff, sometimes within days, preventing the shoulder from moving (called frozen shoulder). Slings limit movement of the shoulder and elbow but allow movement of the hand.

A swathe, which is a piece of cloth or a strap, may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part.

Bed rest, which is occasionally required for fractures (such as some fractures of the spine or pelvis), can cause problems, including blood clots and a decrease in general physical fitness (deconditioning). Thus, bed rest is not commonly recommended.

Commonly Used Techniques for Immobilizing a Joint

Sometimes fractures must be reduced and repaired surgically, as for the following:

• Open fractures: Because the skin was broken, bacteria and debris can enter the body. Doctors must carefully clean the area around the fracture to remove all traces of debris. Doing so reduces the risk of infection.

• Displaced fractures that cannot be aligned or kept aligned by closed reduction: When a piece of bone has shifted or a tendon is in the way, doctors may not be able to realign the broken bones by manipulating them from the outside (closed reduction). Or the fracture can be realigned using closed reduction, but the muscles pull on the pieces of bone and keep them from staying in place.

• Joint surface fractures: These fractures extend into a joint, fracturing the cartilage at the ends of the bones in the joint. To prevent people from developing arthritis later, doctors must almost perfectly realign the fractured cartilage. Realignment can be more precise when it is done surgically.

• Pathologic fractures in a bone weakened by cancer: Bone weakened by cancer may not heal normally after a fracture. Surgery may be needed to prevent the fragments of bone from becoming displaced. Also, stabilizing the joint surgically reduces the pain and enables people to use the joint more quickly.

• Fractures known to require surgery: Certain kinds of fractures (such as hip fractures and thighbone fractures) are known to heal more rapidly and have a better outcome when they are surgically repaired.

• Fractures that would otherwise require a long period of immobilization or bed rest: Surgery shortens the time people have to stay in bed. For example, surgery enables people who have had a hip fracture to get out of bed and begin walking soon after the operation, often as soon as the first day after surgery (with the help of a walker).

• Complicated fractures: Surgery may be required to treat certain injuries that occur with a fracture, such as damaged arteries or severed nerves.

In open reduction with internal fixation (ORIF), surgery is done to restore the bone’s original shape and alignment. X-rays are used to help surgeons see how to align the bones. After making an incision to expose the fracture, the surgeon uses special instruments to align the bone fragments. Then, the fragments are held in place using some combination of metal wires, pins, screws, rods, and plates. For example, metal plates may be shaped as needed and attached to the outside of the bone with screws. Metal rods may be inserted from one end of the bone into the interior of the bone (marrow). These hardware devices are made of stainless steel, high-strength alloy metal, or titanium. The devices that have been made in the last 15 to 20 years do not interfere with the strong magnets used in magnetic resonance imaging (MRI). Most do not set off security devices at airports. Some of these devices are permanently left in place, and some are removed after the fracture has healed.

Joint replacement (arthroplasty) may be needed, usually when fractures severely damage the upper end of the thighbone (femur), which is part of the hip joint, or the upper arm bone (humerus), which is part of the shoulder joint.

In bone grafting, doctors use chips of bone taken from another part of the body (such as the pelvis). This procedure may be done immediately if the gap between pieces of bone is too large. It may be done later if the healing process has slowed (delayed union) or stopped (nonunion).