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 injury is a 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 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 the fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical methods.

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 becomes solid enough to bear 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 bones 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.

Non-unions

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