Fractures

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What is a fracture?

A break in the continuity of a bone.

Fractures like most injuries come in many forms from relatively minor fractures to major life threatening injuries.  The following information will allow you to find out where your fracture fits in this continuum so you have a better understanding of what it is, how and why it occurred, what the healing process involves and what you can do to assist this process.

Causes of Fractures

  1. Traumatic Incident
  2. Repetitive Stress
  3. Pathological (abnormal weakening of the bone)

1. Traumatic Incident

Direct : bone breaks a the point of impact.  This is usually associated with soft tissue damage.

Indirect: bone breaks away from the point of impact and soft tissue injury at the fracture site doesn't always occur.

2. Repetitive Stress

An example of this type of injury is a stress fracture that occurs when muscles become fatigued and are unable to absorb increased shock. Eventually, the fatigued muscle transfers the excess load of stress to the bone causing a tiny crack called a stress fracture. Due to the nature of the overuse injury the bone is not allowed adequate rest to repair after activity.

3.  Pathological

If the bone has become weakened (eg tumour) or brittle (paget's disease, osteoporosis) fractures can occur with normal stresses.

Classification of Fractures

Fractures have many classifications depending on the type of fracture or break and whether it involves other tissues

Open Vs Closed

An open or compound fracture is a fracture where the skin or body cavity is broken/penetrated. Alternatively if the overlying skin remains intact the fracture is said to be closed or a simple fracture.

Stable Vs Unstable

Investigations such as an X-ray or Bone Scan will determine whether the fracture is stable or unstable.  This will determine if surgery is required to stabilise the bone fragments so they heal in a better alignment.  Most open fractures will require surgical fixation.

Type of Fracture

In long bones such as the fingers, the thigh and shin bones the force that causes the fracture will generally determine the shape of the fracture and consequently the management that follows. Bones can break by being twisted (spiral fracture), bent (transverse fracture), bent and compressed, a combination of the above or pulled (avulsion fracture).

Complete or Incomplete

A complete fracture involves the complete width of the bone (there may be some separation of the bones). An incomplete fracture has a fraacture line but the fracture does not cross the whole width of the bone. Some of the edge of hte bone (periosteum) remains intact. This is often known as a greenstick racture.

Healing depends on

  • Type of bone
  • Amount of movement at the fracture site
  • Age
  • General health (e.g. smoker)
  • Nutrition
  • Medications

Five Phases of Healing 

1. Blood Clot Formation:

A haematoma (blood clot) forms around the fracture site.

2. Inflammatory Reaction:

An inflammatory reaction occurs within 8 hours. This involves cellular activity that acts to bridge the fracture and slowly absorb the blood clot.  New blood vessels grow into the area.

3. Callus Formation:

A cellular mass forms a callus (splint) which limit is the movement at the fracture site and dead bone is cleaned up. Generally at 4 weeks following injury the fracture site unites.  The fracture site is incompletely repaired and is unable to withstand unprotected stress.  An X-ray will show a visible fracture line and a fluffy callus will be evident.  The fracture site will still be tender.

4. Union:

At around 6 to 8 weeks new bone is woven into the existing bone and the fracture site consolidates and should be able to withstand normal stresses.  The fracture site should be non-tender and protection is not necessary.

5. Remodelling:

The final stage occurs over months and years following fracture. This is called the remodelling phase. The bone is remodeled to look and work as it was pre-injury.

Timeframe

The amount of time for healing will vary between individuals and will be affected by age, location of fracture, blood supply to the fracture, type of fracture, compliance to treatment etc.

Physiotherapy Management of Fractures 

Management of a fracture is determined by the type and location of the fracture and is specific to the individuals circumstances. The fracture may be placed in a splint, cast, a brace, surgically fixated or placed in traction. Usually they will remain in these period of 4-6 weeks.

Physiotherapy management of fracture may include detection of the fracture after injury and referral or application of the appriopriate intervention. However most physiotherapy management will be after a period of immobilisation and will involve rehabilitation of the structure around the fracture site Physiotherapy may include:

  • Muscle Assessment: Following immobilisation muscles surrounding the fracture site lose bulk, length and strength.   It is very important that a safe exercise program is prescribed and progressed under the supervision of a physiotherapist to restore muscle length and balance and prevent secondary complications occurring.
  • Joint Mobilisation: Joint stiffness often occurs when a limb is not allowed to move for several weeks.  At PhysioSport staff are trained in techniques which can improve and restore range of movement of the affected joints once the fracture has healed.
  • Massage: The release of tight bands and trigger points that occur within muscles following splinting or casting  has been shown to reduce pain and restore muscle length.
  • Heat and Electrotherapy: It is very common for stiffness within soft tissues to occur following prolonged immobilisation.  Heat and Electrotherapy have been shown as useful adjuncts to manual treatment and exercise therapy in relieving pain and restoring muscle length.
  • Gait Education: If your fracture requires the use of gait aids such as crutches then the physiotherapist can advise you with the most appropriate equipment and way of walking that promotes optimal healing and safety.

Remember

  • Seek treatment at an early stage
  • Ensure you physiotherapist provides you with methods of self treatment.