Fractures and 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.

Fractures: Types and Treatment

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.

Growth Plate Fractures

Growth plates, also called the epiphyseal plate or physis, are the areas of growing cartilaginous tissue found at the ends of the long bones in children. These growth plates determine the length and shape of the mature bone. The growth plates are more susceptible to damage from trauma because they are not as hard as bones.

Growth plate injuries commonly occur in growing children and teenagers. In children, severe injury to the joint may result in a growth plate fracture rather than a ligament injury. Any injury that can cause a sprain in an adult can cause a growth plate fracture in a child.

Growth plate fractures are more common in boys than girls because the plates develop into mature bone faster in girls. Growth plate fractures commonly occur at the wrist,, long bones of the forearm (radius) and fingers (phalanges), legs (tibia and fibula), foot, ankle or hip during sports activities such as football, basketball and gymnastics.

Types of growth plate fractures

Growth plate fractures can be classified into five categories based on the type of damage caused.

Type I – Fracture through the growth plate

The epiphysis is separated from the metaphysis with the growth plate remaining attached to the epiphysis. The epiphysis is the rounded end of the long bones below the growth plate and the metaphysis is the wider part at the end of the long bones above the growth plate.

Type II – Fracture through the growth plate and metaphysis

This type is the most common type of growth plate fracture. The growth plate and metaphysis are fractured without involving the epiphysis.

Type III – Fracture through the growth plate and epiphysis

In this type of injury, the fracture runs through the epiphysis and separates the epiphysis and growth plate from the metaphysis. It usually occurs in the tibia, one of the long bone of the lower leg.

Type IV – Fracture through growth plate, metaphysis, and epiphysis:

Type IV is when the fracture goes through the epiphysis and growth plate, and into the metaphysis. This type often occurs in the upper arm near the elbow joint.

Type V – Compression fracture through growth plate: 

This type of fracture is a rare condition where the end of the bone gets crushed and the growth plate is compressed. It can occur at the knee or ankle joint.

Causes

Growth plate injuries are caused by accidental falls or blows to the limbs during sports activities such as gymnastics, baseball, or running. They may also result from overuse of tendons and certain bone disorders such as infection that can affect the normal growth and development of the bone. The other possible causes which can lead to growth plate injuries are:

  • Child abuse or neglect – Growth plate fractures are one of the most common fractures that occur in abused or neglected children.
  • Exposure to intense cold (frostbite) – Extremely cold climatic conditions can cause damage to the growth plates resulting in short fingers and destruction of the joint cartilage.
  • Chemotherapy and medications – Chemotherapy to treat cancer in children and continuous use of steroids for arthritis may affect bone growth.
  • Nervous system disorders – Children with disorders of the nerves may have sensory deficits and muscular imbalances that can cause them to lose their balance and fall.
  • Genetic disorders – Gene mutations may result in poorly formed or malfunctioning growth plates which are vulnerable to fracture.
  • Metabolic diseases – Diseases such as kidney failure and hormonal disturbances affect the proper functioning of the growth plates and increase susceptibility to fractures.

Signs and symptoms

Signs and symptoms of a growth plate injury include:

  • Inability to move or put pressure on the injured extremity
  • Severe pain or discomfort that prevents the use of an arm or leg
  • Inability to continue playing after a sudden injury because of pain
  • Persistent pain from a previous injury
  • Malformation of the legs or arms as the joint area near the end of the fractured bone may swell

In children, fractures heal faster. If a growth plate fracture is left untreated it may heal improperly causing the bone to become shorter and abnormally shaped.

Diagnosis

Your doctor will evaluate the condition by asking you about the injury and performing a physical examination of the child.

X-rays may be taken to determine the type of fracture. Since the growth plates have not hardened and may not be visible, X-rays of the injured as well as the normal limb are often taken to look for differences in order to help determine the place of injury.

Other diagnostic tests your doctor may recommend include computed tomography (CT) scan or magnetic resonance imaging (MRI). These tests are helpful in detecting the type and extent of injury as it allows the doctor to see the growth plate and soft tissues.

Treatment

The treatment for growth plate injuries depends upon the type of fracture involved. In all cases, the treatment should begin as early as possible and include the following:

  • Immobilization: The injured limb is covered with a cast or a splint may be given to wear. The child will be advised to limit activities and avoid putting pressure on the injured limb.
  • Manipulation or surgery: If the fracture is displaced and the ends of the broken bones do not meet in proper position, then your doctor will unite the bone ends into correct position either manually (manipulation) or surgically. Sometimes, a screw or wire may be used to hold the growth plate in place. The bone is then immobilized with a cast to promote healing. The cast is removed once healing is complete
  • Physical therapy: Exercises such as strengthening and range-of-motion exercises should be started only after the fracture has healed. These are done to strengthen the muscles of the injured area and improve the movement of the joint. A physical therapist will design an appropriate exercise schedule for your child.
  • Long-term follow up: Periodic evaluations are needed to monitor the child’s growth. Evaluation includes X-rays of matching limbs at intervals of 3 to 6 months for at least 2 years.

Most growth plate fractures heal without any long term problems. Rarely, the bone may stop growing and become shorter than the other limb.

Nonunions

A fracture is a break in the bone that occurs when extreme force is applied. Treatment of fractures involves the joining of the broken bones either by immobilizing the area and allowing the bone to heal on its own, or surgically aligning the broken bones and stabilizing it with metal pins, rods or plates. Sometimes, the broken bone fails to re-join and heal even after treatment. This is called non-union. Non-union occurs when the broken bones do not get sufficient nutrition, blood supply or adequate stability (not immobilized enough) to heal. Non-union can be identified by pain after the initial fracture pain is relieved, swelling, tenderness, deformity and difficulty bearing weight.

When you present with these symptoms, your doctor may order imaging tests like X-rays, CT scans and MRI to confirm a diagnosis of non-union. The treatment of non-union fractures can be achieved by non-surgical or surgical procedures.

Non-surgical treatment: This method involves the use of a bone stimulator, a small device that produces ultrasonic or pulsed electromagnetic waves, which stimulates the healing process. You will be instructed to place the stimulator over the region of non-union for 20 minutes to a few hours every day.

Surgical treatment: The surgical method of treatment for non-union is aimed at:

  • Establishing stability: Metal rods, plates or screws are implanted to hold the broken bones above and below the fracture site. Support may be provided internally or externally.
  • Providing a healthy blood supply and soft tissue at the fracture site: Your doctor removes dead bone along with any poorly vascularized or scarred tissue from the site of fracture to encourage healing. Sometimes, healthy soft tissue along with its underlying blood vessels may be removed from another part of your body and transplanted at the fracture site to promote healing.
  • Stimulating a new healing response: Bone grafts may be used to provide fresh bone-forming cells and supportive cells to stimulate bone healing.

Stress Fractures

A stress fracture is described as a small crack in the bone which occurs from an overuse injury of a bone. It commonly develops in the weight bearing bones of the lower leg and foot. When the muscles of the foot are overworked or stressed, they are unable to absorb the stress and when this happens the muscles transfer the stress to the bone which results in stress fracture.

Stress fractures are caused by a rapid increase in the intensity of exercise. They can also be caused by impact on a hard surface, improper footwear, and increased physical activity. Athletes participating in certain sports such as basketball, tennis or gymnastics are at a greater risk of developing stress fractures. During these sports the repetitive stress of the foot strike on a hard surface causing trauma and muscle fatigue. An athlete with inadequate rest between workouts can also develop stress fracture.

Females are at a greater risk of developing stress fracture than males, and may be related to a condition referred to as “female athlete triad”. It is a combination of eating disorders, amenorrhea (irregular menstrual cycle), and osteoporosis (thinning of the bones). The risk of developing stress fracture increases in females if the bone weight decreases.

The most common symptom is pain in the foot which usually gets worse during exercises and decreases upon resting. Swelling, bruising, and tenderness may also occur at a specific point.

Your doctor will diagnosis the condition after discussing symptoms and risk factors and examines the foot and ankle. Some of the diagnostic tests such as X-ray, MRI scan or bone scan may be required to confirm the fracture.

Treatment

Stress fractures can be treated by non-surgical approach which includes rest and limiting the physical activities that involves foot and ankle. If children return too quickly to the activity that has caused stress fracture, it may lead to chronic problems such as harder-to-heal stress fractures.

Protective footwear may be recommended which helps to reduce stress on the foot. Your doctor may apply cast to the foot to immobilize the leg which also helps to remove the stress. Crutches may be used to prevent the weight of the foot until the stress fracture is healed completely.

Surgery may be required if the fracture is not healed completely by non-surgical treatment. Your doctor makes an incision on the foot and uses internal fixators such as wires, pins, or plates to attach the broken bones of the foot together until healing happens after which these fixators can be removed or may be permanently left inside the body.

Some of the following measures may help to prevent stress fractures:

  • Ensure to start any new sport activity slowly and progress gradually
  • Cross-training: You may use more than one exercise with the same intention to prevent injury. For example you may run on even days and ride a bike on odd days, instead of running every day to reduce the risk of injury from overuse. This limits the stress occurring on specific muscles as different activities use muscles in different ways
  • Ensure to maintain a healthy diet and include calcium and vitamin D-rich foods in your diet
  • Ensure that your child uses proper footwear or shoes for any sports activity and avoid using old or worn out shoes
  • If your child complains of pain and swelling then immediately stop the activities and make sure that your child rests for few days

Hip

The thigh bone, femur, and the pelvis, acetabulum, join to form the hip joint. The hip joint is a “ball and socket” joint. The “ball” is the head of the femur, or thigh bone, and the “socket” is the cup shaped acetabulum.

The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.

The cartilage cushions the joint and allows the bones to move on each other with smooth movements. This cartilage does not show up on X-ray, therefore you can see a “joint space” between the femoral head and acetabular socket.

Hip Fractures

The hip joint is a “ball and socket” joint. The “ball” is the head of the femur or thigh bone and the “socket” is the cup shaped acetabulum. The joint surface is covered by a smooth articular surface that allows pain free movement in the joint.

Hip fracture is a break that occurs near the hip in the upper part of the femur or thigh bone. The thigh bone has two bony processes on the upper part – the greater and lesser trochanters. The lesser trochanter projects from the base of the femoral neck on the back of the thigh bone. Hip fractures can occur either due to a break in the femoral neck, in the area between the greater and lesser trochanter or below the lesser trochanter.

Hip fracture is most frequently caused after minor trauma in elderly patients with weak bones, and by a high-energy trauma or serious injuries in young people. Long term use of certain medicines, such as bisphosphonates to treat osteoporosis (a disease causing weak bones) and other bone diseases, increases the risk of hip fractures.

Signs and symptoms of hip fracture include

  • Pain in the groin or outer upper thigh
  • Swelling and tenderness
  • Discomfort while rotating the hip
  • Shortening of the injured leg
  • Outward or inward turning of the foot and knee of the injured leg

Your doctor may order an X-ray to diagnose your hip fracture. Other imaging tests, such as the magnetic resonance imaging or (MRI), may also be performed to detect the fracture.

Depending on the area of the upper femur involved, hip fractures are classified as

  • Intracapsular Fracture
  • Intertrochanteric Fracture
  • Subtrochanteric Fracture

Hip fractures can be corrected and aligned with non-operative and operative methods:

Traction may be an option to treat your condition if you are not fit for surgery. Skeletal traction may be applied under local anesthesia, where screws, pins and wires inserted into the femur and a pulley system is set up at the end of the bed to bear heavy weights. These heavy weights help in correcting the misaligned bones until the injury heals.

Hip fractures can be surgically treated with external fixation, intramedullary fixation, or by using plates and screws.

Knee

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

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 orthopedic 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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