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.
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.
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).
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 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.
- 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
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.
Shoulder, Arm, Elbow
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.
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.
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.
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.
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.
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.
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.
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.
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.
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 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.
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.
Elbow Fractures in Children
The elbow is a joint that consists of three bones – the humerus (upper arm bone), radius (forearm bone) and ulna (forearm bone). An elbow fracture most commonly occurs when your child falls on an outstretched arm. It can lead to severe pain in the elbow and numbness in the hand. Fractures are more common in children due to their physical activities as well as their bone properties. Children’s bones have an area of developing cartilage tissue called a growth plate which is present at the end of long bones that will eventually develop into solid bone as the child grows.
Your child’s doctor first evaluates your child’s arm for signs of damage to blood vessels and nerves. An X-ray examination is then ordered to confirm and determine the severity of the fracture. Treatment of elbow fractures depends on the degree of displacement and type of fracture:
- Nonsurgical treatment: If there is little or no displacement from the normal position, nonsurgical treatment is recommended. Your child’s doctor may immobilize the arm using a cast for 3 to 5 weeks. Regular X-rays are ordered to check if the bones are properly aligned.
- Surgical treatment: Surgery may be recommended if the fracture has caused the bones to move out of alignment. Your child’s doctor brings the bones in correct alignment and may use metal pins, screws and wires to hold the bones in place. Your child will have to wear a cast for a few weeks. Exercises to improve the range of motion will be instructed after a month of healing.
Forearm Fractures in Children
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)
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:
- 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
Forearm fractures in children can be diagnosed by analysing X-ray images of the wrist, elbow or the forearm.
The treatment of forearm fractures in children is based on the location, type of fracture, degree of bone displacement and its severity.
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.
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.
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 remodelling (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.
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.
Olecranon (Elbow) Fractures
Three bones, humerus, radius and ulna make up the elbow joint. The bones are held together by ligaments thus providing stability to the joint. Muscles and tendons around the bones coordinate the movements and help in performing various activities. Elbow fractures may occur from trauma resulting from a variety of reasons, some of them being a fall on an outstretched arm, a direct blow to the elbow, or an abnormal twist to the joint beyond its functional limit.
Olecranon fractures: These are fractures occurring at bony prominence of the ulna. The fractures, if stable, are treated using an immobilizing splint followed by a regimen of motion exercises. However severe fractures require surgical repair.
Symptoms of an olecranon fracture include pain, swelling, bruising, stiffness in and around the elbow, a popping or cracking sound, and deformity of the elbow bones.
To diagnose olecranon fractures X-rays of the joint are taken. In some cases, a CT scan may be needed to get to know the details of the joint surface.
The aim of the treatment is to maximize early motion to reduce the risk of stiffness. Nonsurgical treatment options include use of a splint or a sling to immobilize the elbow during the healing process. Surgery is indicated in displaced and open fractures to realign the bones and stabilize the joint as well as to avoid deep infections.
Strengthening exercises, scar massage, therapy with ultrasound, heat, and ice are recommended to improve the range of motion. Splints are also used to facilitate stretching of the joint.
Radial Head Fractures
The elbow is a junction between the forearm and the upper arm. The elbow joint is made up of 3 bones namely the humerus bone in the upper arm which joins with the radius and ulna bones in the forearm. The elbow joint is essential for the movement of your arms and to perform daily activities. The head of the radius bone is cup-shaped and corresponds to the spherical surface of the humerus. The injury in the head of the radius causes impairment in the function of the elbow. Radial head fractures are very common and occur in almost 20% of acute elbow injuries. Elbow dislocations are generally associated with radial head fractures. Radial head fractures are more common in women than in men and occur more frequently in the age group of 30 and 40 years.
The most common cause of a radius head fracture is breaking a fall with an outstretched arm. Radial head fractures can also occur due to a direct impact on the elbow, a twisting injury, sprain, dislocation or strain.
The symptoms of a radial head fracture include severe pain, swelling in the elbow, difficulty in moving the arm, visible deformity indicating dislocation, bruising and stiffness.
Your doctor might recommend an X-ray to confirm the fracture and assess displacement of the bone. Sometimes, your doctor might suggest a CT scan to obtain further details of the fracture, especially the joint surfaces.
The treatment of a fracture depends on the type of fracture.
- Type 1 fractures are usually very small. The bone appears cracked, but remains fitted together. The doctor might use a splint (casting) to fix the bone and you might have to wear a sling for a few days. If the crack becomes intense or the fracture gets deep then your doctor might suggest surgical treatment.
- Type 2 fractures are characterized by displacement of bones and breaking of bones in large pieces and can be treated by surgery. During surgery, your doctor will correct the soft-tissue injuries and insert screws and plates to hold the displaced bone together firmly. Small pieces of bone may be removed if it prevents normal movement of the elbow.
- Type 3 fractures are characterized by multiple broken pieces of bone. Surgery is considered the compulsory treatment to either fix or to remove the broken pieces of bone, sometimes including the radial head. An artificial radius head may be placed to improve the function of the elbow.
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.