What are fractures?

A fracture typically refers to a broken bone. It occurs when a force exerted against the bone is stronger than the bone can structurally withstand. Bones can break either partially or completely in a number of directions, including cross-wise, lengthwise or in the middle. In some cases, fractures cause little pain or may even go unnoticed. Usually patients experience severe or moderate pain.

Less commonly, cartilage can fracture, such as in the trachea, ribs, nose or ear. A bone fracture can also involve fracturing of the cartilage on the end of that bone. Bones form the human frame (skeleton) that supports and protects the organs and other softer parts of the body. Contrary to popular belief, bones are not static or lifeless. They are a form of connective tissue, with new cells replacing old ones throughout a person’s life. Large bones have a center made of marrow, which has cells that develop into red blood cells red blood cells (which carry oxygen to all parts of the body) and white blood cells (which help fight disease). The minerals calcium and phosphorus are also found in bones.

Fractures can occur in any bone but are most likely to occur in the wrist, ankle or hip:

Wrist fractures

Usually occur in the lower end of the radius, the bone on the thumb side of the forearm. This causes backward displacement of the wrist and hand and is often known as a Colles’ fracture. These fractures may occur when a person uses an outstretched hand to try to break a fall.

Ankle fractures

A break in one or more of the three bones – tibia, fibula and talus – that make up the ankle joint. Ankle fractures often also injure one or more of the three groups of ligaments that act to stabilize the ankle joint.

Hip fractures

Often occur after a person falls and usually affect the elderly, who may have brittle bones due to a bone-thinning condition known as osteoporosis. Hip fractures can involve the pelvis or femur (thigh bone). They typically require hospitalization and surgery. Sometimes joint replacement is required. They can result in disability or even death from postoperative complications. In fact, 24 percent of hip fracture patients aged 50 or older die in the first year after the fracture, according to the National Osteoporosis Foundation (NOF).

Other areas prone to fractures include the spine, ribs, arm, fingers, leg, ankle, heel, foot, clavicle (collar bone) and jaw.

Fractures vary in severity, with several factors determining the significance of a fracture. Such factors include the degree and direction of the force placed upon the bone, the type of bone involved and the person’s age and general health.

In some cases, complications may be associated with bone fractures.

These include:

  • Shock. A bad fracture can result in substantial loss of blood due to the rich blood supply found in a bone, which can lead to shock (e.g., thigh bone fracture). Shock is characterized by decreased blood supply to body tissues due to blood loss from the fractured bone, as blood carries oxygen through the body.
  • Injuries to organs. Sometimes, a bone fracture can injure nearby organs. Examples include a skull fracture that injures the brain or a rib fracture that injures organs in the chest cavity.
  • Growth problems. Children who fracture bones may damage the growth plates at the end of bones that regulate bone growth. This can cause the bone to grow at an angle or grow more slowly than normal.

Types and differences of fractures

There are several types of fractures. Bones can either break completely or partially. Complete bone breaks are categorized as:

  • Closed fracture. Fracture that does not lacerate the skin.
  • Open fracture. Also known as a compound fracture, it is a break in which the ends of the broken bone lacerate the skin. In some cases, the blow or injury that caused the break may be responsible for the laceration. The bone may or may not be visible in an open fracture. There is an increased risk of infection with these fractures.
  • Nondisplaced fracture. Fracture in which the pieces on either side of the break line up.
  • Displaced fracture. Fracture in which the pieces on either side of the break do not line up. The bones of displaced fractures may require surgery to make sure they are properly aligned before casting, or may need reduction.
  • Transverse fracture. Fracture at right angles to the long axis of the bone.
There are several types of partial fractures that may occur.

These include:

  • Hairline fracture. Thin break in the bone.
  • Single fracture. Bone that is broken in one place.
  • Segmental fracture. Bone that is broken in two or more places.
  • Comminuted fracture. Bone that is broken into more than two pieces or crushed.
  • Stress fracture. Breaks in bone caused by unusual or repeated stress.
  • Spiral fracture. Bone that is broken through twisting, causing a fracture that follows a spiral line.
  • Compression fracture. Breaking of vertebrae by pressure along the vertebral column, often involving osteoporosis.
  • Avulsion fracture. Bone that is broken due to a ligament or tendon that is attached to the bone, pulling away part of the bone.
  • Intraosseous fracture. Also known as a bone bruise or bone contusion, a condition in which traumatic impact causes bone pain, tenderness, swelling of soft tissues and possibly microfractures.

Finally, there are two types of fractures that are more likely to occur in children. Children’s bones are more likely to bend than to break because their bones are softer than adults. They are:

  • Buckle or torus fracture. One side of the bone bends – creating a raised “buckle” – without breaking the other side.
  • Greenstick fracture. Partial fracture in which one side of the bone is broken and the other side bends.
Children also are vulnerable to fractures that damage the growth plates at the end of bones that regulate bone growth. If growth plates do not heal properly after a fracture, the bone may grow at an angle or grow more slowly than normal. For this reason, pediatricians closely monitor fractures in children to ensure that no damage to the growth plate has occurred.

Risk factors and potential causes of fractures

There are many causes of bone fractures.

These include:

  • Trauma. Injuries, such as those sustained in a car wreck, sports or a fall from a ladder, account for most fractures.
  • Osteoporosis. A disease that results in the loss of bone density. It most often affects women after menopause but is also common in elderly men. Osteoporosis leaves the bone fragile and susceptible to breaks. Hip fractures, which may result in severe pain in the hip or groin, are a common and dangerous type of fracture associated with osteoporosis.
  • Other bone disorders. These less-common conditions include:
    • Bone tumors such as osteosarcoma
    • Paget’s disease, a metabolic disease that involve abnormal breakdown and regrowth of bone.
    • Osteomalacia, a condition in which the bones soften because of a lack of vitamin D or difficulty metabolizing this vitamin. In children this disease is known as rickets.
    • Osteogenesis imperfecta, an inherited disease that causes extremely fragile bones.
  • Overuse. Putting too much stress on bone can result in stress fractures, which are tiny cracks in the bone. Such injuries are common among athletes and tend to appear most often in the lower leg or foot.

Other conditions that may increase the incidence of fractures include:

  • Systemic lupus erythematosus. Lupus dramatically increases the risk of osteoporosis.
  • Rheumatoid arthritis. These patients also are prone to osteoporosis.
  • Juvenile rheumatoid arthritis and other forms of juvenile arthritis. Physical inactivity, inflammation, delayed puberty and inadequate nutrition may help explain these patients’ elevated risk of broken bones in adolescence and beyond.
  • Sickle cell anemia. This inherited blood disease can cause necrosis (tissue death) in shoulder or hip joints, which may require treatment with arthroplasty.
  • Diabetes. Diabetic patients have been found to have higher rates of falls and hip fractures than nondiabetics.
  • Male hypogonadism (testosterone insufficiency). Low levels of testosterone, a common condition in middle-aged and elderly men, can weaken bones.

In addition, people can experience dizziness due to conditions such as vertigo or orthostatic hypotension (a drop in blood pressure when moving from sitting to standing) or medications such as antihypertensives, anesthetics or some birth control pills. These individuals are advised to take precautions against fainting and falls.

Some medical treatments can increase the risk of osteoporotic fractures. They may include radiation therapy to the pelvic area, use of corticosteroids (taken for a wide range of conditions, from herniated discs to carpal tunnel syndrome to asthma), hormone therapy for prostate cancer, and possibly use of certain anticoagulants.

Signs and symptoms of fractures

When a person fractures a bone, it is usually obvious. A snap or cracking sound may be evident, followed by pain, tenderness and swelling. In some cases, a limb may be deformed, or the bone may penetrate the skin.

When a bone fractures, emergency care should be summoned if the injury is serious. This includes situations in which the patient is seriously injured in the head, neck or back, or if the broken bone lacerates the skin.

Other symptoms that indicate a need for emergency medical care include:

  • Person is unresponsive. Cardiopulmonary resuscitation (CPR) should be performed if the person is not breathing or has no heartbeat.
  • Heavy bleeding.
  • Pain with even gentle movement or pressure.
  • Limb or joint appears deformed.
  • Toe or finger of an injured limb is numb or bluish at the tip.

Stress fractures are tiny cracks in a bone that usually result from overuse or repetitive application of force (such as the pavement against a foot bone during jogging). Stress fractures may be barely noticeable when they first occur, but may get worse over time. A femoral stress fracture in the thigh is a common condition in runners.

Symptoms associated with stress fractures include:

  • Dull ache after physical activity
  • Swelling
  • Pain that decreases with rest and increases with activity
  • Pain that appears earlier in each successive workout
  • Pain that gets progressively worse over time
  • Tenderness or pain in certain areas when pressure is applied

In contrast, the first sign of a spinal compression fracture is a decrease in the person’s height. Pain is often a late symptom that may go unnoticed in the beginning, although in some cases excruciating pain is felt early. Osteoporosis is a common predisposing factor for compression fractures.

Diagnosis methods for fractures

Fractures typically diagnose themselves, as most people experience symptoms that make it obvious that they have broken a bone. However, a physician will typically review a medical history and perform a physical examination (including checking for swelling and tenderness).

The following tests may also be performed to confirm a diagnosis:

  • X-rays. Use low doses of radiation to produce images on film or fluorescent film.
  • Bone scan. A type of radionuclide imaging that is sensitive in diagnosing bone disease.
  • MRI (magnetic resonance imaging). Uses powerful magnets to produce images on a computer screen and film.
  • CAT scan (computed axial tomography). Uses multiple x-rays to create cross-sectional images of the body.

Stress fractures can be more difficult to diagnose and may not always appear on an x-ray. However, patients who suffer stress fractures often experience pain, tenderness and mild swelling.

A cartilage fracture, such as to the costal cartilage in the ribs, may be diagnosed with a CAT scan or ultrasound.

Treatment options for fractures

When a fracture is suspected, the patient should seek immediate medical care. If the injury appears to be serious, an ambulance should be called. Less serious injuries can be stabilized through the following steps:

  • Remove clothing from the injured area. If necessary, use scissors to remove clothing rather than trying to force an injured limb through a sleeve or pant leg.
  • Apply a cold compress or an ice pack wrapped in cloth to the area.
  • Place a makeshift splint on the injured body part. This should consist of soft padding around the injured part and be taped together with something firm, such as a board or rolled-up newspaper. The firm piece should extend above and below the injured part to help keep it in place.
  • Seek medical care. Avoid eating in case surgery is needed.
The body itself begins the first step in the treatment of a fracture. When a fracture occurs, the body forms a protective blood clot and callus or fibrous tissue. New bone cells begin to grow on either side of the fracture line and eventually grow toward each other. This closes the fracture and the callus is absorbed.

To aid this natural healing process, physicians may use casts, splints, pins or other devices to hold a fracture in the correct position while it heals. The two major types of immobilization devices are:
  • External fixation methods. Include plaster and fiberglass casts, cast-braces, splints and other devices. Casts are usually used on fractures, as they encircle the injury and keep it completely fixed in place. However, less serious fractures may require less stringent forms of immobilization, such as a splint (which supports the fractured bone on one side only).
  • Internal fixation methods. Use metal plates, pins or bone screws to hold the broken pieces of bone in proper position during healing.
In cases of a displaced fracture - where the bone breaks and comes out of alignment - the bone will need to be set back in the right position. This is known as a closed reduction, and it is performed before casting, splinting or other similar procedures. In more serious cases, surgery may be necessary to successfully realign the bone.

Patients who have casts placed around arm fractures will sometimes be given a sling. This is a piece of cloth with a strap that loops around the back of the neck. Patients place their arm in the cloth, which rests over the chest and abdomen. Slings make it easier for people to support the weight of the cast. Patients who have casts placed around a leg may be given crutches to help them keep weight off the affected leg.

Some fractures, such as a broken hip due to osteoporosis, may require joint replacement. Vertebral fractures may also require surgery.

Fractures usually take anywhere from several weeks to several months to heal. However, pain typically subsides enough to allow the patient to resume using the bone in normal activities long before the fracture has healed.

Stress fractures often require less treatment than traditional fractures and can be healed with cryotherapy and rest. However, casts, splints and surgery all are sometimes used to treat more significant stress fractures.

Prevention methods for fractures

Not all fractures can be prevented. However, people can take steps to strengthen their bones and make them less susceptible to breaking. Weight-bearing exercises, such as jumping rope, jogging, walking and weight training can strengthen bones by increasing a person’s bone mass.

The risk of stress fractures can be reduced by warming up and stretching before physical activity, which is frequently the cause of these types of fractures. It also helps to start new exercise programs slowly and to build up intensity gradually. People should also wear the appropriate footwear and avoid what are known as the “terrible toos” – exercising too much, too fast, too hard and for too long.

People can also reduce their risk of fractures by taking precautions against trauma, such as wearing seatbelts and observing bicycle safety rules.

Diets with adequate amounts of calcium, vitamin D and possibly soy can decrease the risk of osteoporosis, a bone-thinning disease that often leads to fractures. Some high-risk patients are prescribed osteoporosis medications such as bisphosphonates to help strengthen their bones. These drugs can reduce the risk of fractures by between 40 and 60 percent, according to the Arthritis Foundation. The American College of Rheumatology recommends bisphosphonates for people who require long-term corticosteroid therapy for conditions such as asthma.

Scientists have found that the risk of fractures may be lower in people taking certain medications for other conditions, such as beta blockers (used to treat high blood pressure and some heart conditions) or statins (used to control cholesterol).

Questions for your doctor on bone fractures

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about fractures:

  • Am I at high risk for fractures? Do I need to take precautions against osteoporosis or other conditions?
  • Is there a difference between a “broken bone” and a “fracture”?
  • If I do not feel any pain, does this mean I have not fractured a bone?
  • What tests might I need to diagnose a fracture?
  • What do my test results show? What type of fracture do I have?
  • What are my treatment options?
  • How can a cast or splint help me?
  • Could I need surgery for my fracture?
  • How do I know if a fracture has healed?
  • If I fracture a bone, is it more likely to fracture or break in the future?
  • Are there treatments that can help strengthen my bones?
  • How can I prevent fractures in the future?

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