Fractures & Trauma

A bone fracture is a medical condition in which a bone is cracked or broken. It is a break in the continuity of the bone. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis.

The word “Fracture” implies to broken bone. A bone may get fractured completely or partially and it is caused commonly from trauma due to fall, motor vehicle accident or sports. Thinning of the bone due to osteoporosis in the elderly can cause the bone to break easily. Overuse injuries are common cause of stress fractures in athletes.

Types of fractures include:

  • Simple fractures in which the fractured pieces of bone are well aligned and stable.
  • Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
  • Open (compound) fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.
  • Greenstick fractures: This is a unique fracture in children that involves bending of one side of the bone without any break in the bone.

Fracture Healing

Our body reacts to a fracture by protecting the injured area with a blood clot and callus or fibrous tissue. Bone cells begin forming on the either side of the fracture line. These cells grow towards each other and thus close the fracture.

Medical Therapy

The objective of early fracture management is to control bleeding, prevent ischemic injury (bone death) and to remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical method.

Non-operative (closed) therapy

comprises of casting and traction (skin and skeletal traction).

  • Casting closed reduction is done for any fracture that is displaced, shortened, or angulated. Splints and casts made up of fiberglass or plaster of Paris material are used to immobilize the limb.
  • Traction Traction method is used for the management of fractures and dislocations that cannot be treated by casting. There are two methods of traction namely, skin traction and skeletal traction.

Skin traction involves attachment of traction tapes to the skin of the limb segment below the fracture. In skeletal traction, a pin is inserted through the bone distal to the fracture. Weights will be applied to this pin, and the patient is placed in an apparatus that facilitates traction. This method is most commonly used for fractures of the thighbone.

Surgical Therapy

  • Open Reduction and Internal Fixation (ORIF) This is a surgical procedure in which the fracture site is adequately exposed and reduction of fracture is done. Internal fixation is done with devices such as Kirschner wires, plates and screws, and intramedullary nails.
  • External fixation External fixation is a procedure in which the fracture stabilization is done at a distance from the site of fracture. It helps to maintain bone length and alignment without casting.

External fixation is performed in the following conditions:

  • Open fractures with soft-tissue involvement
  • Burns and soft tissue injuries
  • Pelvic fractures
  • Comminuted and unstable fractures
  • Fractures having bony deficits
  • Limb-lengthening procedures
  • Fractures with infection or non-union

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of cast or brace so that the bone become solid enough to bear the stress. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete.

Knee and Leg

Fractures of the Proximal Tibia

The tibia or shin bone is a major bone of the leg which connects the knee to the ankle. A tibial fracture is a break in the continuity of the shin bone (tibia).

Fractures of proximal tibia: A proximal tibial fracture is a break in the upper part of the shin bone or tibia. Proximal tibial fractures may or may not involve the knee joint. Fractures that enter the knee joint may cause joint imperfections, irregular joint surfaces, and improper alignment in the legs. This can lead to as joint instability, arthritis, and loss of motion. These fractures are caused by stress or trauma or in a bone already compromised by disease, such as cancer or infection. Proximal tibia fractures can result in injury to the surrounding soft tissues including skin, muscle, nerves, blood vessels, and ligaments.

The symptoms of tibia fracture include painful weight bearing movements, tenseness around the knee, limitation of movement and deformity around the knee. In some individuals, impairment of blood supply secondary to the fracture may result in a pale or cool foot. Patients may also experience numbness or feelings of ‘pins and needles’ in the foot as a result of associated nerve injury.

The diagnosis of tibial fracture is based on the medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate a soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.

The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.

Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.

Surgical treatment is considered to maintain alignment of the fractured bone. External or internal fixators may be used to align the fractured bone segments. If the fracture does not involve the knee joint, rods and plates can be used to stabilize the fracture. For a fracture involving the knee joint, a bone graft may be required to prevent the knee joint from collapsing. An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plate and screw may be harmful.

As the tibial fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.

Pediatric Thighbone (Femur) Fracture

The femur or thighbone is the largest and strongest bone in the human body. Pediatric thighbone fractures can occur when your child falls hard on the ground and gets hit during sports, automobile accidents, and child abuse. In a thighbone fracture, the broken bones may be aligned or displaced. The fracture can either be closed (with skin intact) or open (with the bone piercing out through the skin). Your child may experience severe pain, swelling, inability to stand and walk, and limited range of motion of hip or knee.

Your child’s doctor will conduct a physical examination. An X-ray or CT-scan may be recommended to locate the position and number of fractures, and determine if the growth plate is damaged. Femur fractures may be treated with non-surgical or surgical methods.

Non-surgical treatment involves stabilizing the bones so they can heal and fuse together. Braces, spica casting (cast applied from the chest, down the fractured leg) or traction (placing the leg in a weight system) may be used to ensure that the bones are properly set in their normal position.

Surgery is recommended for complicated injuries. Your child’s surgeon aligns the broken bones and uses metal plates and screws to hold the fractured bones together in proper alignment. Your child may have to wear a cast for a few weeks until complete healing. An external fixator may be used in case of open injury to the skin and muscles.

Shinbone Fractures

The tibia or shin bone is a major bone of the leg which connects the knee to the ankle. A tibial fracture is a break in the continuity of the shin bone (tibia).

Types

  • Fractures of proximal tibia: A proximal tibial fracture is a break in the upper part of the shin bone or tibia. Proximal tibial fractures may or may not involve the knee joint. Fractures that enter the knee joint may cause joint imperfections, irregular joint surfaces, and improper alignment in the legs. This can lead to as joint instability, arthritis, and loss of motion. These fractures are caused by stress or trauma or in a bone already compromised by disease, such as cancer or infection. Proximal tibia fractures can result in injury to the surrounding soft tissues including skin, muscle, nerves, blood vessels, and ligaments.
  • Tibial shaft fractures: A tibial shaft fracture is a break that occurs along the length of the tibia or shin bone (larger bone of the lower leg) between the knee and ankle joints. These fractures can occur while playing sports such as soccer and skiing.

The symptoms of tibia fracture include painful weight bearing movements, tenseness around the knee, limitation of movement and deformity around the knee. In some individuals, impairment of blood supply secondary to the fracture may result in a pale or cool foot. Patients may also experience numbness or feelings of ‘pins and needles’ in the foot as a result of associated nerve injury.

The diagnosis of tibial fracture is based on the medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate a soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.

The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.

Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.

Surgical treatment is considered to maintain alignment of the fractured bone. External or internal fixators may be used to align the fractured bone segments. If the fracture does not involve the knee joint, rods and plates can be used to stabilize the fracture. For a fracture involving the knee joint, a bone graft may be required to prevent the knee joint from collapsing. An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plate and screw may be harmful.

As the tibial fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.

Thighbone (Femur) Fracture

The femur or thigh bone is the longest and strongest bone in the body, connecting the hip to the knee. A femur fracture is a break in the femur. The distal femur is the lower part of the thigh bone which flares out like an upside-down funnel and its lower end is covered by a smooth, slippery articular cartilage that protects and cushions the bone during movement. Fracture of the distal femur may involve the cartilaginous surface of the knee as well and result in arthritis.

Types

  • Distal femur fracture: The distal femur is part of the femur bone that flares out like the mouth of the funnel. A distal femur (top part of knee joint) fracture is a break in thighbone that occurs just above your knee joint.
  • Femoral shaft fracture: A femoral shaft fracture is a break that occurs anywhere along the femoral shaft, long, straight part of the femur.
  • Proximal femur fracture: A hip fracture or proximal femur fracture is a break in the proximal end of the thigh bone near the hip.

Femur fractures may be caused by high energy injuries such as a fall from height or a motor vehicle accident. Patients with osteoporosis, bone tumor or infections, or a history of knee replacement are more prone to femur fractures. In the elderly, even a simple fall from a standing position may result in a fracture as the bones tend to become weak and fragile with advancing age.

Sudden, severe pain along with swelling and bruising are the predominant symptoms of femur fracture. The site is tender to touch with a visible physical deformity and shortening of the leg.

The diagnosis of femur fracture is based on the patient’s medical history including history of any previous injuries, complete physical examination and imaging studies. The physician will evaluate the soft tissue around the joint to identify any signs of nerve or blood vessel injury. Multiple X-rays and other imaging studies such as CT and MRI scans may be used to identify the location and severity of the fracture.

The management of the fracture is based on the severity of the fracture, medical condition of the patient and the patient’s lifestyle.

Non-surgical treatment comprises of immobilizing the fractured site with the help of casts or braces to prevent weight bearing and to help the healing process. X-rays are taken at regular intervals to assess the healing process. Weight bearing and movement are initiated gradually, depending on the nature of the injury and the condition of the patient.

Surgical treatment is considered to realign the fractured bone. The use of advanced technology and special materials has improved the surgical outcome even in older patients. External or internal fixation or a knee replacement may be required depending on the extent of the fracture. Timing of the surgery is an important factor in improving the surgical outcome.

Timing of surgery

In most cases, the surgery is delayed for a few days to develop an effective treatment plan and for preparation of the patient. With most distal femur fractures the surgery can be delayed unless the fracture is open to the environment.

External fixator

An external fixator is used when the surrounding soft tissue is severely damaged, as the use of plates and screws may be harmful. The external fixator maintains the alignment of the bone till surgery.

Once the patient is prepared for surgery, the surgeon removes the external fixator and places internal fixation devices into the bone during surgery.

Internal fixator

The internal fixation may be performed using intramedullary nailing or plates and screws. In intramedullary nailing a metal rod is inserted into the marrow canal of the femur to keep the fractured fragment in position. In the plate and screw method the bone fragments are realigned and held together with screws and plates, attached to the outer surface of the bone. If the fracture is of the comminuted type or the bone has broken into many pieces, plates or rods may be used at the ends of the fracture without disturbing the smaller pieces. The plate or rod will maintain the shape or strength of the bone till it heals. In elderly patients and those with poor bone quality, bone grafting may be used to improve the healing. Knee replacement may also be considered in complicated fractures or those with poor bone quality.

Knee replacement

Artificial implants may be used to replace the fractured segments of the bone and joint.

Rehabilitation

Rehabilitation of the femur fracture depends upon several factors such as age, general health of the patient and the type of fracture. As the femur fracture usually involves the weight bearing joint it may cause long term problems such as loss of knee motion or instability and long term arthritis. Hence a rehabilitation program is initiated along with the treatment comprising of instructions on weight bearing, knee movements, and the use of external devices such as braces.

Shoulder, Arm

Broken Arm

The forearm is made up of 2 bones namely the radius and ulna. The primary function of your forearm is rotation i.e., the ability to turn your palms up and down. The fracture of the forearm affects the ability to rotate your arm, as well as bend and straighten the wrist and elbow. The breaking of the radius or ulna in the middle of the bone requires a strong force and it is most commonly seen in adults. In most of the cases, both bones are broken during a forearm fracture.

The forearm bones can break in several ways. The bones can crack slightly or can break into many pieces. Forearm fractures are generally due to automobile accidents; direct blow on the forearm or fall on an outstretched arm during sports, climbing stairs, etc.

Symptoms

The symptoms of a forearm fracture include intense pain in the arm, bruises and swelling. Your fractured forearm may appear bent and shorter compared to your other arm. You may experience numbness or weakness in the fingers and wrist. You may be unable to rotate your arm. Rarely, a broken bone sticks out through the skin or the wound penetrates down to the broken bone.

Diagnosis

Your doctor may conduct a physical examination and record your medical history initially. Your doctor may feel your arm thoroughly to determine tenderness. You may be asked to get an X-ray done to determine displaced or broken bones.

Treatment

Usually people with forearm fractures are immediately rushed to the emergency room for treatment. Treatment of forearm fracture aims at putting back the broken bones into position and preventing them from moving out of place until they are completely healed.

Nonsurgical Treatment

In case only one bone is broken and is not out of place, your doctor might treat it with a cast or brace and provide a sling to keep your arm in position. Your doctor will closely monitor the healing of the fracture. If the fracture shifts in position, you may be advised to undergo surgery to fix the bones back together.

Surgical Treatment

When both forearm bones are broken, surgery is usually required. During surgery, the cuts from the injury will be cleaned and the bone fragments are repositioned into their normal alignment. They are held together with screws and metal plates attached to the outer surface of the bone. The incision is sutured firmly and a sling is provided to facilitate healing.

Broken Collarbone

The clavicle or the collarbone is the bone that connects your sternum or breastbone to your shoulder. Clavicle fracture, also called broken collarbone is a very common sports injury seen in people who are involved in contact sports such as football and martial arts as well as impact sports such as motor racing.

Causes

A broken collarbone normally occurs after a fall onto the shoulder or a motor vehicle accident. The most common sports associated with clavicle fractures include football, hockey, and skiing.

Symptoms

A broken collarbone most often causes pain, swelling and bruising over the collarbone. Pain increases with shoulder movement. Your shoulder may be slumped downward and forward. You may also have a bump around the area of the break. You may hear a grinding sound when you try to raise your arm.

Diagnosis

To diagnose a broken collarbone, your doctor will take a brief history, about the injury, and perform a physical examination of your shoulder. An X-ray of the clavicle is taken to identify the location of the fracture. Your doctor may also recommend a computerized tomography (CT) scan in some cases.

Conservative Treatment Options

Most broken collarbones heal without a surgery. An arm sling may support the arm and hold the bones in their normal position. You may also be given pain medications to relieve the pain. After your pain reduces your doctor may recommend gentle shoulder and elbow exercises to minimize stiffness and weakness in your shoulder. Follow up with your doctor until your fracture heals.

Surgery

Surgery may be required in case of displaced fractures. Surgery is performed to re-align the fractured ends and stabilize them during healing. Surgery often involves use of pins or plates and screws to maintain proper position of the bone during healing.

Plates and Screws fixation

During this surgical procedure, your surgeon will reposition the broken bone ends into normal position and then uses special screws or metal plates to hold the bone fragments in place. These plates and screws are usually left in the bone. If they cause any irritation, they can be removed after fracture healing is complete.

Pins

Placement of pins may also be considered to hold the fracture in position and the incision required is also smaller. They often cause irritation in the skin at the site of insertion and have to be removed once the fracture heals.

Forearm Fractures in Children

Introduction

The radius (bone on the thumb side) and ulna (bone on the little-finger side) are the two bones of the forearm. Forearm fractures can occur near the wrist, near the elbow or in the middle of the forearm. Apart from this, the bones in children are prone to a unique injury known as a growth plate fracture. The growth plate, which is made of cartilage (flexible tissue) is present at the ends of the bones in children and helps in the determination of length and shape of the mature bone.

The healing of fractures in children is quicker than that in adults. Thus, if a fracture is suspected in a child, it is necessary to seek immediate medical attention for proper alignment of the bones.

Types of fractures

Forearm bones may break in many ways. Fractures may be “open” where the bone protrudes through the skin, or “closed” where the broken bone does not pierce the skin. The common types of fractures in children include:

  • A stable fracture that compresses the bone on one side, forming a buckle on the opposite side of the bone, without breaking the bone (Buckle or torus fracture)
  • One side of the bone breaks and bends the bone on the other side (Greenstick fracture)
  • Displacement of the radius, and dislocation of the ulna at the wrist where both bones meet (Galeazzi fracture)
  • Fracture affecting the upper or lower portion of the bone shaft (Metaphyseal fracture)
  • Fractured ulna and dislocated head of the radius (Monteggia fracture)
  • Fracture occurring at or across the growth plate (Growth plate fracture)

Causes

Forearm fractures in children are caused due to a fall on an outstretched arm or direct hit on the forearm, which may result in breakage of one or both bones (radius and ulna).

Signs and Symptoms

A fractured forearm causes severe pain and numbness. Other signs and symptoms include:

  • Swelling
  • Tenderness
  • Inability to turn or rotate the forearm
  • Deformed forearm, wrist or elbow
  • Bruising or discoloration of the skin
  • Popping or snapping sound during the injury

Diagnosis

Forearm fractures in children can be diagnosed by analyzing X-ray images of the wrist, elbow or the forearm.

Treatment

The treatment of forearm fractures in children is based on the location, type of fracture, degree of bone displacement and its severity.

Non-surgical therapy

Your child’s doctor will advise you to apply an ice pack over a thin towel on the affected area for 15-20 minutes 3-4 times a day, to relieve pain and swelling. For severe angled fractures, in which the bones have not broken through the skin, your doctor will align the bones properly without the need for surgery (closed reduction). A splint or cast may be required for 3 to 4 weeks for a stable buckle fracture. Immobilization for 6 to 10 weeks is recommended for more serious fractures.

Surgical Treatment

Surgery may be necessary for severe fractures such as fractures of the growth plate or the joint. Other conditions, such as broken skin, bone displacement, unstable fractures, misaligned bones, and bones healing in an improper position may also require surgical repair. Your surgeon will first align the bones through an incision and use fixation devices like pins or a metal implants to hold the bones in place while the wound heals. A cast or a splint may be placed to hold the bones in place.

Conclusion

In the long run, the forearm of your child may have a slightly different or crooked look than before the fracture, which is normal. It may take around 1-2 years for the bones of the forearm to straighten while the bones undergo the process of remodeling (reshaping). For growth plate fractures, your child’s doctor will carefully monitor the hand for many years to ensure that growth occurs normally.

Fracture of the Shoulder Blade (Scapula)

The scapula (shoulder blade) is a flat, triangular bone providing attachment to the muscles of the back, neck, chest and arm. The scapula has a body, neck and spine portion.

Scapular fractures are uncommon but do occur and require a large amount of force to fracture. They are usually the result of intense trauma, such as a high-speed motor vehicle accident or a fall from height onto one’s back. They can also occur from a fall on an outstretched arm if the humeral head impacts on the glenoid cavity.

Symptoms of a scapular fracture include the following:

  • Pain: Usually severe and immediate following injury to the scapula.
  • Swelling: The scapular area quickly swells following the injury.
  • Bruising: Bruising occurs soon after injury.
  • Impaired Mobility: Decreased range of motion of the joint occurs, often with inability to straighten the arm.
  • Numbness: Numbness, tingling, or coldness of the hand and forearm can occur if blood supply is impaired or nerves are injured.
  • Popping Sound: A cracking or popping sound, also referred to as crepitus, can often be heard or felt at the time of the fracture.

Scapular fractures should be evaluated by an orthopaedic surgeon for proper diagnosis and treatment.

Your surgeon will perform the following:

  • Medical History
  • Physical Examination

Diagnostic Studies may include:

  • X-rays: A form of electromagnetic radiation that is used to take pictures of bones.
  • CT scan: This test creates images from multiple X-rays and shows your physician structures not seen on regular X-ray.
  • MRI: Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments.

Most scapular fractures are not significantly displaced due to the strong supporting soft tissue structures surrounding it. Therefore, a majority of scapular fractures are treated conservatively and with early motion to reduce the risk of stiffness and will usually heal without affecting shoulder movement.

Conservative treatment options include:

  • Immobilization: A sling is used for comfort and to support the shoulder to allow healing to take place. This is usually worn about 3-6 weeks depending on the type of fracture and how well you heal.
  • Prescription Medications: Pain medications will be prescribed for your comfort during the healing process.
  • Physical Therapy: Early progressive range of motion exercises is essential in restoring full shoulder function. Your physician will most likely refer you to a Physical Therapist for instruction on proper exercises and early motion of the shoulder to prevent complications.

Surgical Introduction

Fractures of the scapula involving the neck or glenoid or with severe displacement have been associated with poor outcomes when treated non-operatively. will usually require surgical intervention to realign the bones properly and restore a functional, pain free range of motion to the shoulder joint.

Scapular fracture repair surgery has historically been performed through a large, open incision. Newer, minimally invasive techniques have evolved and surgery to repair scapular fractures can now be performed through arthroscopy.

Shoulder Trauma

Shoulder injuries most commonly occur in athletes participating in sports such as swimming, tennis, pitching, and weightlifting. The injuries are caused due to the over usage or repetitive motion of the arms.

Shoulder injuries cause pain, stiffness, restricted movements, difficulty in performing routine activities, and popping sensation.

Some of the common shoulder injuries include sprains and strains, dislocations, tendinitis, bursitis, rotator cuff injury, fractures, and arthritis.

  • Sprains and strains: A sprain is stretching or tearing of ligaments (tissues that connect adjacent bones in a joint). It is a common injury and usually occurs when you fall or suddenly twist. A strain is stretching or tearing of muscle or tendon (tissues that connect muscle to bone). It is common in people participating in sports. Strains are usually caused by twisting or pulling of the tendons.
  • Dislocations: A shoulder dislocation is an injury that occurs when the ends of the bone is forced out of its position. It is often caused by a fall or direct blow to the joint while playing contact sport.
  • Tendinitis: It is an inflammation of a tendon, a tissue that connects muscles to bone. It occurs as a result of injury or overuse.
  • Bursitis: It is an inflammation of fluid filled sac called bursa that protects and cushions your joints. Bursitis can be caused by chronic overuse, injury, arthritis, gout, or infection.
  • Rotator cuff injury: The rotator cuff consists of tendons and muscles that hold the bones of the shoulder joint together. Rotator cuff muscles allow you to move your arm up and down. Rotator cuff injuries often cause a decreased range of motion.
  • Fractures: A fracture is a break in the bone that commonly occurs as a result of injury, such as a fall or a direct blow to the shoulder.
  • Arthritis: Osteoarthritis is the most common type of shoulder arthritis, characterized by progressive wearing away of the cartilage of the joint.

Early treatment is necessary to prevent serious shoulder injuries. The immediate mode of treatment recommended for shoulder injuries is rest, ice, compression and elevation (RICE). Your doctor may also prescribe anti-inflammatory medications to help reduce the swelling and pain.

Your doctor may recommend a series of exercises to strengthen shoulder muscles and to regain shoulder movement.

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