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Fractures - Broken bones

Definition and causes

A fracture is a condition in which a bone is damaged from being exposed to a greater force than it can withstand. Every year many people are affected by fractures of various bones.

The most commonly affected are the bones of the wrist, fingers, feet and toes. Other bones, damaged by injury (work and traffic accidents, etc.) are typically larger bones such as those in the arms, legs, hips and spine.

Fracture damage can generally be categorized in relation to the force with which the damage occurred. We are therefore talking about fractures stemming from high energy (large force such as traffic accidents, etc.) and low energy fractures involving less force such as sports injuries, etc. and spontaneous fractures occurring seemingly unprovoked, at minimal force, mostly due to illness in the bone or related causes

Fractures are most frequently dealt with by protecting the fracture area with a cast or other treatment, which gives the bone stability and rest to grow together again. For more complex fractures, it is often necessary to operate to get the bone in the correct position again and stabilize the bone with metal wires, screws or other (see below).

However, there are many different reasons for fractures. The most common types of fractures, and how they arise, are as follows:

Stress fractures:

The smallest fractures are called stress fractures which are usually a result of several small injuries in the same place for example repeated small twists or by repeated heavy load which the body is not accustomed to (for example a marathon runner who has increased the training intensity too much).

The stress fracture will be seen as small cracks in the bone and the bone is not broken as such. Stress fractures can be difficult to see on a normal x-ray and it might be necessary to make a bone scintigraphy where a radioactive substance is injected into the bone. This substance will attach to the bone and will show possible stress fractures using a special camera (gamma camera) which picks up radioactivity.

Displaced and simple or transverse fractures:

Adults do not have supple bones as children, and therefore fractures of varying degrees might happen with bigger or smaller accidents in adults. If the fracture has occurred across the width of a bone with the two ends still in place together it is a simple fracture. With increasing age, the bones become less elastic and there is a greater risk of fractures, where the bone ends have shifted and no longer fit together. This is called a displaced fracture. - Fractures across the bone width are also called transverse fractures.

The fracture in the bone can appear in different ways. The fracture might run across the width of the bone, run at an angle along the bone or as a spiral around the bone. In some cases the fracture might breach a joint surface which can be serious, and later lead to the development of arthritis.

Open fractures – compound fractures:

When the two bone ends have shifted much, there is a risk that the bone is doing damage to muscles, blood vessels and nerves. In some cases one or both bone ends puncture the skin. Such cases are called open fractures or a compound fractures. For open fractures there is a greater risk of infection with bacteria, and therefore such cases must be treated with antibiotics right away.

Spontaneous fractures:

Spontaneous fractures occur most frequently in older people and are caused by a change in bone structure and the bone cannot withstand the same pressures as in the past. This is typical in osteoporosis cases where one or several vertebrae may fracture and crumble resulting in loss of height and damaged to spinal nerves and severe pain. Spontaneous fractures can also be caused by another illness like bone cancer, where among other things fractures in the femur bone are frequent.

Fractures in children:

In children, there is another type of fracture, which is called a greenstick fracture. The name greenstick because a child’s bones can break as a fresh branch where a long bone in the arm or leg bends and the bone cracks on one side only. This is because children's bones are not fully developed and suppler than an adult bone.

Another type of fracture in children is a break in the bone growth zone (the epiphysis) called a epiphyseal fracture, The epiphyseal plate might shift with such fractures and adversely affect the subsequent growth. Surgery may be necessary to put the plate in place to ensure continued growth of normal bone. In major accidents, children, like adults, can also incur both simple and displaced fractures (see above).

Symptoms of fractures.

The most common symptoms of a fracture are:
  • Pain.
  • Reduced movement.
  • Swelling and discoloration.
  • Possibly deform appearance.
Unless there is a clear deform appearance, the symptoms might be similar to a severe sprain.

Precautions and diagnosis.

The vast majority of fractures occur in the context of an accident, and if you suspect that a bone is broken, you should go to the emergency room or doctor. During a thorough examination, the physician may assess whether there is a need to take an X-ray to confirm or deny the diagnosis.

In apparent fracture cases an X-ray will always be taken to determine the right treatment.

Treatment of fractures.

The treatment of fractures depends on several things including:
  • The location of the fracture? (hands, ankles, legs, arms, back, etc.).
  • What type of fracture? (transverse, simple, spiral, displaced).
  • How serious is the fracture? (open fracture, damage to arteries, muscles and nerves).
Depending on the above the overall treatment principles will be decided. Conservative treatment i.e. without surgery, or surgery.

Conservative treatment.

Conservative treatment of a fracture, will usually involve different types of bandages, which can immobilize the fracture to varying degrees.
  • Taping is used for small fractures of fingers and toes. The tape must not be too tight as it can then block the blood flow to the area.
  • Support bandage is an elastic bandage used only for very small fractures. The bandage partially immobilizes the fracture, but also increases the awareness of the fracture and in this way patients take greater care and stay quiet.
  • Arm sling is often used for fractures of the upper arm or a collarbone also called the clavicle bone. The arm hangs in the sling and is kept at rest. It is important to keep the shoulder mobilized as the joint capsule may otherwise stiffen.
  • Plaster cast is used if much immobilization is needed. The cast is put onto a thin cotton wool wrapping. The cast might fully cover the broken limp or only one side and then held in place with an elastic bandage. Depending on the fracture type and location the cast is usually kept in place for 2 to 8 weeks.
  • Some types of fractures are treated only with pain medication. An example of such is a broken rib, unless there are multiple rib fractures. In the latter case the patient will often be hospitalized for observation.

Surgical treatment.

If the fracture is bigger or complicated surgery might be required and the fracture undergo internal or external fixation.

Internal fixation involves the use of various orthopedic nails, screws, threads and plates of various metal alloys.

External fixation involves the use of metal pins inserted through the skin tissue and into the bone around the fracture and locked into position using an externally positioned (outside the body) metal frame often called a Hoffmann fixation.

Outlook and complications.

The progression and outlook for a fracture depends on the treatment. Conservatively treated fractures usually require a recovery period of 2 to 8 weeks.

The outlook and recovery period can vary considerably depending on type of fracture, but also the patient's age and whether complications like infection set in play a role. A fracture having undergone surgery might not take longer to recover than a conservatively treated fracture. 

For both conservatively and surgically treated fractures, one must reckon with a period of limited activity, stiffness around the fracture and a period of pain. The duration of this period is very individual.

A complication with a fracture might be that the bone ends do not grow together in precise position resulting in a malposition. This can sometimes lead to a sustained reduction of functionality. In cases where the bone ends fail to grow together a fibrous joint (a false joint also named pseudarthrosis) may arise where the bone can be bent, as in other joints.

For complicated fractures, especially open fractures, there is always a risk of infection, which in severe cases can spread to the bone. This condition is called osteomyelitis.

Many hospitalized, especially with fractures in the legs, are at risk of getting a blood clot in the deep veins in the leg. Attempt to prevent this involves administration of anti coagulation, or blood thinning medication.

A serious complication of rib fractures is that the fractured rib punctures the lung. This is called pneumothorax. At left sided rib fracture may also damage the spleen, which may bleed.

Everyone who suffers a fracture will lose muscle mass, flexibility and movement control after a period of immobilized treatment. Rehabilitation of varying nature is therefore an important treatment of a bone fracture. Children will usually have a high activity level as soon as the pain is gone and will soon be as agile as before.

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