Did you know that each of us, on average, will have two bone fractures over the course of our lifetime? Naturally, some people, on account of their vocations, avocations and lifestyles, will have more. Human activity can generate fractures of every bone in the body. Some bones, like the skull bones and ribs, form protective compartments for certain vital organs. Other bones provide the framework for muscles, tendons, and other locomotor structures that allow us to move about in our environment. This discussion will deal with the more common fractures which are sustained in day to day activities.
First of all, let’s discuss the kinds of fractures. One category involves whether the fracture is complete with separate bone fragments, or incomplete where bone fragments still partially joined. Another category is open fracture versus closed fracture. An open fracture is usually caused by a bone fragment puncturing the skin, so that the fracture is exposed to the outside. A closed fracture does not communicate directly with the outside, i.e., there is no broken skin. Other fractures, such as linear, spiral, or transverse, have to do with the fracture’s relationship to the long axis of the bone, that is, lengthwise, around, or across the bone. If the fracture has more than one fragment, it is called comminuted.
The basic principle in treating a fracture, both in first aid and in definitive care by a physician, is fracture immobilization. Applying a splint or other device to prevent movement of the fracture is of utmost importance. If a broken bone is moved, it can rupture nutrient blood vessels, cause further bleeding around the fracture, or even convert a closed fracture to an open one.
The second thing a physician has to address is whether there is nerve damage or blood vessel damage associated with the fracture. An entrapped nerve or artery would usually necessitate surgical treatment of the fracture.
The third thing that has to be assessed is fracture gap and angulations of the fracture deformity. If a fracture is too widely separated or angulated, surgery and internal fixation deices to repair the fracture may be needed. The final determinant is whether the fracture is open or closed. An open fracture has to be treated surgically to ensure the maximal possibility of healing.
Most fractures can be treated by external splinting or casting. The rule is to cast one joint above and one joint below the fracture, so that the tendons and muscles won’t tug on the fracture site and prevent healing. The initial healing process involves the laying down of fibrocyte cells at the injury site which produce a rubbery substance called collagen. This collagen is gradually calcified over the next several weeks as the fracture heals. Calcification can usually be seen by x-ray at six to eight weeks, but total fracture healing may require several months. One common place to sustain a fracture is the wrists and lower forearms. People tend to thrust their hands out in front of them to break a fall, and this often causes these fractures. A common fracture of the wrists of children and the elderly is the Colles Fracture, which produces a dinner-fork deformity of the wrist due to the angulated fracture of the radius bone. Most wrist and forearm fractures respond well to closed reduction (manipulation to reduce the angle and gap) and heal well with casting.
Another common fracture is the collar bone, or clavicle. This often occurs from a fall on the elbow or shoulder. It is treated with a sling and usually knits back together well, though there is often a temporary fracture deformity. Occasionally the fracture ends have to be surgically joined.
Rib fractures usually occur from direct blows to the ribs. They are very painful, but there is not an adequate way to splint them. An elastic rib belt was once used, but was found to cause pneumonia on the affected side. So the main treatment is enough pain medicine for comfort until the ribs start to heal and the pain subsides.
Skull fractures usually occur from direct blows. Because of the proximity to the brain, cranial nerves, and facial structures, their evaluation and treatment usually fall to neurosurgeons, ENT surgeons, or oral surgeons.
Compression fractures of the spine can occur from bone aging, or from major decelerative injuries. If there is impingement on the spinal cord or nerve roots, neurosurgeons or specialized orthopedic surgeons assume their care. Hip fractures are, as we know, common in the elderly. This is because their bones are weakened and brittle by the osteoporosis of aging, and they are more prone to falls. Usually surgery is required to retain function of the hip, and the healing process is prolonged.
It takes a lot of force to fracture a healthy femur, the big bone of the upper leg. This usually occurs in a fall from height or a motor vehicle accident. The fracture is often treated with traction to reduce it, and may require open surgery.
Fractures of the ankle are common in sports, falls, and motor vehicle accidents. If angulation and gap distance are not excessive after reduction, and if there isn’t tendon separation, these are most often treated with cast applications.
That’s the topic of fractures in a nutshell. The physician treating a fracture has a lot of factors to consider. He needs to mentally calculate the strength and direction of forces which caused the fracture. He needs to study the exact nature of the fracture with x-rays or maybe a CT scan. He must determine if there is concomitant nerve, blood vessel, or tendon injury. Finally he must determine whether the fracture can be managed by reduction and splinting or casting, or if it will need surgical correction.
John Drew Laurusonis
Doctors Medical Center