Fractures

A fracture, also referred to as a crack, break, greenstick, hairline or buckle fracture is a medical condition where the continuity of the bone is broken. A significant percentage of bone fractures occur because of high-energy trauma. In children it is inevitable that the fracture is usually due to high-energy impact. In older adults and some children the fracture may also be the result of some medical conditions, which weaken the bones, for example osteoporosis, some cancers or osteogeneris imperfecta. A fracture caused by a medical condition is known as a pathological fracture.

The word break is commonly used by lay (non-professional) people. Among health care professionals, especially bone specialists, such as orthopaedic surgeons, break is a much less common term when talking about bones.

A fracture can occur with no skin damage and this is referred to as a closed fracture. If there is skin breakage then this is a significant fracture with a significant risk of infection and amputation even with early surgical treatment.

The location of the fracture can also have an impact on the treatment and outcome. If the fracture is within the joint for example the risk of stiffness across the joint becomes significantly increased. However if the fracture is away from the joint the risk becomes less. For this reason fracture that extend into the joint need more careful attention to obtaining perfect reduction.

• Femur fracture Femur fracture
• Femur fracture Femur fracture
• Femur fracture Femur fracture
• Femur fracture Femur fracture
• Femur fracture Femur fracture
•  

Fractures in children are also very different. The reason for this is that children have growth plates and therefore can tolerate varying degrees of deformity. Despite how the bone sets, the younger the child the more likely they are going to remodel (reshape) the bone to give a normal appearing bone. Only a paediatric orthopaedic surgeon can assess and guide treatment for this. On the other hand children’s fractures around the growth plate can cause significant deformity to the child during growth.

Because children's bones are more elastic, when they do have fractures they tend to be different. Children also have growth plates at the end of their bones - areas of growing bone -, which may sometimes be damaged.

Some different types of fracture:

• Avulsion fracture - a muscle or ligament pulls on the bone, fracturing it.

• Comminuted fracture - the bone is shattered into many pieces.

• Compression (crush) fracture - generally occurs in the spongy bone in the spine. For example, the front portion of a vertebra in the spine may collapse due to osteoporosis.

• Fracture dislocation - a joint becomes dislocated, and one of the bones of the joint has a fracture.

• Greenstick fracture - the bone partly fractures on one side, but does not break completely because the rest of the bone can bend. More common among children, whose bones are softer and more elastic.

• Hairline fracture - a partial fracture of the bone. Often this type of fracture is harder to detect.

• Impacted fracture - when the bone is fractured, one fragment of bone goes into another.

• Longitudinal fracture - the break is along the length of the bone.

• Oblique fracture - A fracture that is diagonal to a bone's long axis.

• Pathological fracture - when an underlying disease or condition has already weakened the bone, resulting in a fracture (bone fracture caused by an underlying disease/condition that weakened the bone).

• Spiral fracture - A fracture where at least one part of the bone has been twisted.

• Stress fracture - more common among athletes. A bone breaks because of repeated stresses and strains.

• Torus (buckle) fracture - bone deforms but does not crack. More common in children. It is painful but stable.

• Transverse fracture - a straight break right across a bone.

  • Tibia Plateau Fracture Tibia Plateau Fracture
  • Tibia Plateau Fracture - Post Tibia Plateau Fracture - Post
  • Tibia Plateau Fracture - Post Tibia Plateau Fracture - Post
  •  

How is a fracture diagnosed?

Dr Balakumar will use an X-ray and sometimes may require either a MRI scan or other imaging modalities to diagnose the fracture.

What are the treatment options for a bone fracture?

Bone healing is a natural process, which in most cases will occur automatically. Fracture treatment is usually aimed at making sure there is the best possible function of the injured part after healing. Treatment also focuses on providing the injured bone with the best circumstances for optimum healing (immobilization).

For the natural healing process to begin, the ends of the broken bone need to be lined up - this is known as reducing the fracture.

The options for this are:

Immobilization

as soon as the bones are aligned they must stay aligned while they heal.

This may include:

• Plaster casts or plastic functional braces - these hold the bone in position until it has healed.

• Metal plates and screws - current procedures use minimally invasive techniques.

• Intra-medullary nails - Internal steel rods are placed down the center of long bones. Flexible wires may be used in children.

• External fixators - these may be made of metal or carbon fiber; they have steel pins that go into the bone directly through the skin. They are a type of scaffolding outside the body.

Usually the fractured bone area is immobilized for between two to eight weeks. The duration depends on which bone is affected and whether there are any complications, such as a blood supply problem or an infection.

Example

Monteggia fracture-dislocation of the forearm in a 12 year old with internal fixation

Healing

If a broken bone has been aligned properly and kept immobile the healing process is usually straightforward.

Osteoclasts (bone cells) absorb old and damaged bone while osteoblasts (other bone cells) are used to create new bone. Callus is formed; callus is new bone which is formed around a fracture. It forms on either side of the fracture and grows towards each end until the fracture gap is filled. Eventually the excess bone smoothes off and the bone is like it used to be before.

The patient's age, which bone is affected, the types of fracture, as well as the patient's general health are all factors, which influence how rapidly the bone heals. If the patient smokes regularly the healing process will take longer.

Physiotherapy

After the bone has healed it may be necessary to restore muscle strength as well as mobility to the affected area. If the fracture occurred near or through a joint there is a risk of permanent stiffness - the individual may not be able to bend that joint as well as before.

Surgery

If there was damage to the skin and soft tissue around the affected bone or joint, plastic surgery may be required.

Delayed unions and non-unions

Non-unions are fractures that fail to heal, while delayed unions are those that take longer to heal.

• Ultrasound therapy - low-intensity ultrasound is applied daily to the affected area. This has been found to help the fracture to heal. Studies in this area are still ongoing.

• Bone graft - if the fracture does not heal a natural or synthetic bone is transplanted to stimulate the broken bone.

• Stem cell therapy - studies are currently underway to see whether stem cells can be used to heal fractures that do not heal.

What are the possible complications of a bone fracture?

• Heals in the wrong position - this is known as a malunion; either the fracture heals in the wrong position or it shifts (the fracture itself shifts).

• Disruption of bone growth - if a childhood bone fracture affects both ends of bones, there is a risk that the normal development of that bone may be affected, raising the risk of a subsequent deformity.

• Persistent bone or bone marrow infection - if there is a break in the skin, as may happen with a compound fracture, bacteria can get in and infect the bone or bone marrow, which can become a persistent infection (osteomyelitis). Patients may need to be hospitalized and treated with antibiotics. Sometimes surgical drainage and curettage is required.

• Bone death (avascular necrosis) - if the bone loses its essential supply of blood it may die.

Prevention of fractures

Nutrition and sunlight - the human body needs adequate supplies of calcium for healthy bones. Milk, cheese, yoghurt and dark green leafy vegetables are good sources of calcium. Our body needs Vitamin D to absorb calcium - exposure to sunlight, as well as eating eggs and oily fish are good ways of getting Vitamin D.

Physical activity - the more weight-bearing exercises you do, the stronger and denser your bones will be. Examples include skipping, walking, running, and dancing - any exercise where the body pulls on the skeleton.

Older age not only results in weaker bones, but often in less physical activity, which further increases the risk of even weaker bones. It is important for people of all ages to stay physically active.

The (female) menopause - estrogen, which regulates a woman's calcium, starts to drop and continues to do so until after the menopause; levels never come back up to pre-menopausal levels. In other words, calcium regulation is much more difficult after the menopause. Consequently, women need to be especially careful about the density and strength of their bones during and after the menopause. The following steps may help reduce post-menopausal osteoporosis risk:

• Do several short weight-bearing exercise sessions each week.

• Do not smoke.

• Consume only moderate quantities of alcohol, or don't drink it.

• Make sure you get adequate exposure to daylight.

• Make sure your diet has plenty of calcium-rich foods. For those who find this difficult, talk to your doctor about taking calcium supplements.

Dr Balakumar treats all fractures in the body.