Fractures

Bones can fracture in a number of different ways. This can be a simple crack across the shaft of a bone –known as a transverse fracture. In long bones, such as the femur (thigh bone) a more complex, spiral, fracture is more common. This leaves surfaces that are less likely to reunite easily.

Usually, an injury results in a single fracture, and is known as a simple fracture. Sometimes, especially in more serious accidents, a bone can fracture in a way that produces several fragments. This is called a comminuted fracture.

After a fracture, the broken fragments of bone usually separate to some degree. Sometimes, the broken fragments can be wedged together. This is called an impacted fracture.

Bones can also fracture as a result of exposure to repeated small stresses and strains. This is known as a stress fracture and is most often seen in the lower leg or foot bones, especially in athletes.

Sometimes the broken end of a bone protrudes through the skin. This is known as a compound (open) fracture and it can lead to infection.

From about middle-age onwards, the bones begin to become less dense and more liable to fracture. Osteoporosis refers to a condition of brittle bones where this process is accelerated. It particularly affects women after the menopause. See the separate factsheet on osteoporosis.

Fractures in children tend to be different to those in adults. The bone is softer, and more able to bend. When fractures occur, the bone is not always broken completely. The bone can buckle and split and result in what is known as a greenstick fracture (like snapping a young, green twig).
Another type of fracture common in children is called a growth plate fracture. Bone grows in length from special areas near the ends of longer bones, known as the growth plates (epiphyseas). Fractures can sometimes involve these areas and interfere with future growth of the bone.

The most obvious symptom of a fractured bone is pain, especially on movement. There is often swelling and bruising at the site of the fracture. The fractured bone may have an abnormal bent appearance and this may be obvious. It may be impossible to move a fractured part of the body, either as a direct result of the fracture or because of the pain it causes.
Someone who has fractured a bone can appear pale and clammy and experience nausea or light-headedness. This is often due to pain. When large bones, such as the pelvis or thighbone (femur) are fractured, there will be internal bleeding from the bone and this can cause similar symptoms.

For someone who is conscious, breathing and does not have open wounds, the most important aspect of first aid treatment is to minimise movement of the fractured bone. This helps minimise pain and can also prevent further injuries caused by movement of the sharp ends of broken bone. How a fracture is immobilised depends on where the fracture is. It may be necessary to use a sling or form a splint. These techniques can be learnt from first aid courses and manuals.
It's important to seek medical advice for anyone with a suspected broken bone.

Most fractures can be clearly diagnosed by X-ray, although some types, such as a fracture of the base of the thumb, or a stress fracture, do not show up reliably.

After serious accidents, or where a person has circulation or breathing problems, or other serious injury that affects these essential processes, doctors treat these first. Fractures are then treated as follows:

• Re-aligning the broken bone, if necessary. This may needs to be done with the use of an anaesthetic, painkillers or both of these and is known as reducing the fracture.
• Immobilising the broken bone. Plaster casts, splints or slings may be used. Some fractures require surgery, and the use of metal screws, wires, pins or plates to hold the broken pieces of bone together. This is may be necessary where the broken ends of bone cannot easily be brought back together or kept close enough to allow them to knit together.

Recovery

The repair of a fracture by the body is a gradual, continuous process. The time it takes for the broken ends of the bone to knit back together (unite) varies depending on the type of fracture and where the fracture is. As a general rule, fractures need to be immobilised for between two and eight weeks. After this it is important to begin gentle movement and exercise as this helps to build up strength in the healing bone over the following months. Physiotherapy may be needed to promote healing and a return to mobility of the affected bone.

Occasionally there can be complications with fractures. Very serious fractures can heal with some limitations – such as pain or stiffness – in the use of the limb or joint involved.

Some fractured bones do not knit back together well and can lead to a slow recovery, with surgery needed to help the bones to unite.

Infection can also complicate and delay the healing of fractures. This is more common if the fracture was a open or if surgery has been required to fix the bone.

Yes. It's important that you keep your cast in good condition and prevent it from being damaged, so that it can give your bones the support they need to heal.

The purpose of your cast is to keep your bones still and in the right place so that they can heal properly. If your cast becomes damaged, it's less likely to give your fracture the support it needs.

There are two main types of cast used to immobilise fractures: plaster of Paris casts and synthetic casts.

Plaster of Paris casts are the most common type used. Once they are put on, they can take around two days to dry out fully. They are easy to damage while still damp, so you will need to protect the cast until it has dried. For the first couple of days while it is still damp:

• try to rest your cast on a soft surface like a pillow
• don't put any weight on the plaster if you have broken your foot or leg

  Once your plaster of Paris cast has dried out, it's important that you don't get it wet as this will permanently damage it. Take the following steps to stop it from getting wet.
  
  

• Cover your cast with a special cover or plastic bag when you shower or bath.
• Remove the cover promptly to limit damp from condensation.
• If the plaster cast reaches the top of your thigh, take care to prevent it from getting wet or soiled when you go to the toilet.

There are a number of types of synthetic casts, including ones made from fibreglass. Synthetic casts dry out much faster than plaster casts, usually setting within 20 or 30 minutes. You can get some synthetic casts wet once they are dry, whereas others you need to keep dry. Ask your doctor or nurse about your kind of cast.

If your cast becomes cracked or uncomfortable, you should go back to the accident and emergency department.

Yes. You can lower your risk of fractures in later life by taking steps to build strong and healthy bones while you are younger. There are also things you can do to minimise your risk of falling over as you age.

A good way to protect against fractures in later life is to build strong and healthy bones while you are young. Try to follow these lifestyle points.

• Eat a healthy diet, including foods rich in calcium (such as dairy products), vitamin D (such as oily fish and egg yolks) and vitamin K (such as broccoli and spinach).
• Spend time in the sunshine - your body makes vitamin D naturally when your skin is exposed to sunlight. The exact time you need is different for everyone, but is typically only a few minutes in the middle of the day. However, do not let your skin redden. 
• Take vitamin D supplements. If you don't get enough sun exposure and particularly during winter months, taking up to 25 micrograms of vitamin D a day (two high-strength 12.5 microgram capsules) can help to make sure you get enough. 
• Be active - try to do different activities to help build up strength, flexibility and balance. For example, Tai Chi and dance can help you to be more flexible, while walking and cycling can improve your muscle strength.
• Maintain a healthy weight for your height - osteoporosis and fractures are more common in people who are underweight.
• Don't smoke - smoking also has an effect on your bones.

  If you think you might be prone to accidents or falling over, ask your GP if there are any treatments or services that could help you. He or she may suggest the following.

• Strength and balance training - this is a programme of exercises designed to strengthen your muscles and improve balance.
• A home hazard assessment - this is where an occupational therapist comes to your home to check for hazards that might cause a fall.
• An eye test.

  The following practical day-to-day tips can also help to stop you from having an accident at home.

• Keep your home free of clutter and tuck away any cables.
• Make sure your pets don't get under your feet.
• Store everyday items at an easy height for you to reach.
• Keep your home well lit, particularly stairways.
• Wear well-fitting shoes.
• Put a rubber mat in the bath and install a grab rail.

Yes, a sprain can sometimes give the same symptoms as a broken bone. If you're not sure what your injury is, you should see your GP.

A sprain is an injury to ligaments - the strong fibres that hold your joints together. If you tear a ligament, you can sometimes get the same symptoms as a broken bone, particularly if the sprain is severe. These include:

• swelling and bruising
• pain
• movement of the joint that isn't normal, and which may get worse as time goes on, until you can't move the joint at all
• a snapping or breaking sound at the time of the accident, if the ligament has broken

You may not be able to tell whether you have broken a bone or sprained a joint, so it's important to get medical advice. If you have any of these symptoms, you should see your GP or go to your nearest accident and emergency department. Your doctor may need to take an X-ray or scan to be sure

• WebMD http://my.webmd.com/content/healthwise/46/11365

Sources

• Fractures. The Merck manuals online medical library.www.merck.com/mmpe, accessed October 2007
• Dandy DJ, Edwards DJ. Essential orthopaedics and trauma. 3rd ed. New York: Churchill Livingstone, 1998: 45-6, 90, 94-5
• McRae D. Practical fracture treatment. 3rd ed. New York, 1996: 4-9, 87
• Stress fracture. eMedicine.www.emedicine.medscape.com, accessed August 2009
• MacAuley D. Oxford handbook of sports and exercise medicine. Oxford, 2007: 54
• Simon C, Everitt H, van Dorp F. Oxford handbook of general practice. 3rd ed. Oxford: Oxford University Press, 2010: 516, 1106
• Ruedi TP, Buckley RE, Moran CG. AO Principles of fracture management. 2nd ed. New York: Thieme, 2007
• McLatchie G, Borley N, Chikwe J. Oxford handbook of clinical surgery. 3rd ed. Oxford: Oxford University Press, 2007: 454-7
• Busse JW, Bhandari M, Kulkarni AV, et al. The effect of low-intensity pulsed ultrasound therapy on time to fracture healing: a meta-analysis. Can Med Assoc J, 2002; 166(4): 437-41
• Low intensity pulsed ultrasound for promotion of fracture healing (consultation in progress). National Institute for Health and Clinical Excellence (NICE).www.nice.org.uk, accessed 23 February 2010
• Alexander M, Fawcett J, Runciman P. Nursing practice hospital and home: the adult. 3rd ed. Edinburgh: Churchill Livingstone, 2006: 451-2
• Altizer L. Casting for immobilization. Orthop Nurs, 2004; 23(2): 138-40
• Healthy bones. National Osteopororis Society.www.nos.org.uk, accessed 28 December 2009
• Vitamins and minerals. Food Standards Agency.www.eatwell.gov.uk, accessed 28 December 2009
• Bone and joint health. British Nutrition Foundation.www.nutrition.org.uk, accessed 28 December 2009
• An introduction to osteoporosis. National Osteopororis Society.www.nos.org.uk, accessed 28 December 2009
• Clinical practice guideline for the assessment and prevention of falls in older people. National Institute for Health and Clinical Excellence (NICE), 2004.www.nice.org.uk
• Caring for your bones: advice for older people. Help the Aged.www.helptheaged.org.uk, accessed 28 December 2009
• Sprain and strains. Clinical Knowledge Summaries.www.cks.nhs.uk, accessed 4 January 2010