Fractures

Fracture Types

Fractures are described by their location, the degree of displacement, and whether or not the bone has broken through the skin. In lay terms, it is sometimes assumed that a break is more serious than a fracture; to a physician, both refer to the same thing. A fracture that is incomplete or not fully through the bone may be a stress fracture, which often results from overuse in the foot, leg, or hip of a runner, for example. A complete fracture that is fully through the bone may be described as either nondisplaced (hairline crack) or displaced (the two parts not aligned), ranging from minimally displaced to widely displaced. If a bone is broken into many pieces rather than cleanly, it is referred to as a comminuted fracture. The former term for a broken bone that has gone through the skin was compound fracture; now this is described as an open fracture. A fracture where the bone does not pierce the skin is a closed fracture. Thus, a person with an open, widely displaced, comminuted tibia fracture has a shinbone that is broken into many pieces, is badly out of place, and has gone through the skin.

Fracture Healing

Fracture healing varies by age, location, severity of the fracture, and treatment method. In general, children's bones heal much faster than those of adults. In a baby a long bone may heal in a few weeks, whereas in a 6-year-old child the same bone may take 6 weeks and in an adult 6 months to fully heal. When a bone fractures, first a blood clot forms, much like a scab forms on cut skin. Next, the cells in the blood clot recruit bone-forming cells (osteoblasts), which begin making new bone. At first, this bone is poorly organized and looks cloudy on an X-ray. This is called callus. Usually, enough callus is present to allow weight bearing by 6 weeks after the fracture. Over time, this new bone solidifies and reorganizes into a strong new bone. This is called remodeling. The process of remodeling takes from several months to several years after the injury. Images (a)–(d) on page 560 depicts a displaced tibia (shinbone) fracture treated with a cast and its progressive healing over the next 6 months in an 11-year-old boy. In children particularly, bones have wonderful remodeling properties. It is possible in a child to have a bone heal very crookedly and straighten itself out without help over time. It should be mentioned that good nutrition, in particular 400 international units [Page 560](IU)/day of vitamin D and 1,000 milligrams (mg)/day of calcium, is very important for fracture healing.

(a) Initial comminuted tibia fracture in an 11-year-old boy, (b) initial callus at 6 weeks, (c) able to walk independently at 3 months, and (d) bone well remodeled at 6 months and back to playing hockey

Source: Photos courtesy of Children's Orthopaedic Surgery Foundation.

Fracture Treatment Methods

Fracture treatment varies widely by the age of the patient and the severity of the injury. For some fractures, crutches or a sling may be all that is needed. For more severe fractures, surgery with a rod or plate and screw fixation may be needed. The following are the guidelines for fracture treatment.

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