1. What is a broken bone (fracture)?
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Bones make up the skeleton of the body. They allow us the ability to interact with our
environment and lift out body up against gravity. Bones are attachment points for
muscles which allows us to run, jump, sit, kneel, grasp, and lift. Bones also protect
organs from potential damage, and the bone marrow (tissue inside of bones) is
responsible for blood cell production.
Bones are the body's storage area for calcium. On a cellular level, calcium is always
entering and exiting bone under the influence of the body's hormones. Parathyroid
hormone increases calcium levels in the bloodstream, meaning, that it regulates it's
release by bone and decreasing bone density. Calcitonin decreases blood calcium
levels and helps restore calcium to bone. Calcium is needed in the blood stream to
help muscle cells including the heart to function. Hormone levels will sacrifice
calcium in bone to maintain blood calcium levels in a normal range. For that
reason, calcium and Vitamin D are important to maintain calcium stores in the body.
What causes a broken bone?
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When a bone has an outside force exerted upon it, like a blow or a fall, there is
potential that it cannot withstand the amount of force and it breaks. That loss of
integrity results in a fracture. It is important to remember that a fracture, break, or
crack all describe the same situation, an injury to the bone where it has been
damaged. One term is not more serious than another. Fracture, break, and crack all
mean the same thing.
Depending upon the situation, the amount of force required may not be very great.
People with osteoporosis, the bones lack calcium and are brittle, a minor injury or
even gravity may create enough of a force to cause a vertebral compression fracture
of the back or a hip fracture.
What are the most common types of broken bones?
Fractures are usually described by their location, how the bones are aligned, whether
there are associated complications with blood and nerve function, and whether the
skin is intact at the injury site.
2. The terms and definitions used in medicine to describe fractures allow health care
professionals to describe exactly where in the bone the fracture is located. For a
reference point, the heart is considered the center of the body and the anatomic
descriptions are based on their location in reference to the heart. When describing a
location on or in the body, imagine standing straight up, looking forward with the
arms slightly away from your side, and the palms turned forward.
Common anatomic terms used to describe fractures include the following:
Proximal (closer to the center of the body) and Distal (further from the center):
the elbow is proximal to the wrist and the wrist is distal to the elbow.
Anterior (toward the front of the body) and Posterior (toward the back): The
chest is anterior to the back and the back is posterior to the chest.
Medial (toward the middle of the body) and Lateral (to the outer edge of the
body): The ears are lateral to the nose and the nose is medial to the ears.
By thinking of the body in the anatomic position, fractures can be described by their
location in the bone and how the parts are aligned and related to each other.
Fractures are either displaced or non-displaced, meaning that they are adequately
aligned or not. Some physicians suggest that all fractures have some displacement
and prefer the term "minimally displaced."
The description of the fracture also includes the direction it takes within the bones.
Transverse: the fracture travels across the bone
Oblique: the fracture occurs at an angle
Spiral: –the fracture spirals or extends down the length of the bone
Comminuted: the fracture has more than two parts, multiple fragments are
Greenstick: In children, there may not be enough calcium to solidify the bone
and when force is applied, it tends to bow and not break completely through.
The term comes from a similar situation when trying to break a young branch off
Torus: In an adult, when only one part of a bone buckles it is called a torus or
3. Open fracture: An open fracture describes the situation where the bone
penetrates through the skin.
The skin is very important in protecting the inside of the body from infection. If the
skin overlying a broken bone is damaged, whether it is cut, torn or scraped, there is
potential for bacteria from the outside world to invade the broken bone and cause
Fractures are classified as open (if the skin is damaged) or closed (if the skin is
intact). An open fracture may require an orthopedic surgeon to wash out the fracture
site to prevent osteomyelitis (bone infection). Depending upon circumstances, the
type of fracture, the amount of contamination to the skin and wound, and the
person's condition, this procedure may take place in the operating room.
Bone Fractures Illustration - Fracture of Bone
The spine is comprised of 7 cervical, 12 thoracic, and 5 lumbar vertebrae. The spine
holds the body erect against gravity and to protect the spinal cord. Compression
fractures can be caused by osteoporosis, injury, or trauma.
People with osteoporosis lose calcium from the bones, and the vertebrae may
become weak and unable to hold up against the forces of gravity, so they
gradually compress over time.
A compression fracture due to an injury may or may not have spinal cord or
nerve root irritation because of the fracture.
4. A compression fracture due to trauma most likely occurs from a motor vehicle
crash or fall from height.
The purpose of the skull is to protect the brain. It is a flat bone and it takes a
significant direct blow to cause a fracture. Because the main concern is an injury to
the brain and not the skull injury , plain X-rays are not routinely performed to look for
a skull fracture. Instead CT scan of the brain is recommended if there is concern
about a brain injury. Skull fractures are often associated with localized swelling and
bleeding at the site of injury.
Basilar skull fractures describe damage to bone at the base of the brain. Physical
findings may include bloody drainage from the ear or nose, bruising behind the ear
(Battle's sign), and bruising around the eyes (Raccoon eyes).
With a depressed skull fracture, the bone is broken and one piece is pushed inward.
Depending upon depth of the bony depression and whether there is brain tissue
involvement, surgery may be required.
With an open skull fracture, the scalp is lacerated and the wound may connect with
the fibrous coverings of the brain (meninges). Surgery is often performed to help
Stress fractures are the result of multiple microtraumas where the bone cannot
tolerate and absorb repeated stresses placed upon it. It is an overuse injury and is
often seen in the lower leg especially with runners and other athletes. If untreated,
and if the person continues to participate in offending activity, the stress fracture
may progress to a completed fracture. These are most often seen in athletes who
participate in running, tennis, basketball, and other sports that involve running and
jumping on hard surfaces.
March fracture is the name given to a stress fracture of the metatarsal bone of the
foot. They are described in soldiers who are forced to walk or "march" for prolonged
What are the most common bones that are broken?
The most common fractures involve the clavicle (collarbone), the forearm (radius and
ulna), the wrist, the ankle and the hip. Closed fractures are more common than open
fractures (the skin overlying the injury is intact and not damaged).
5. In children, a fracture of the distal radius is most common. The break occurs in the
radius near the wrist but usually does not involve the joint itself. 1
What are the signs and symptoms of a broken bone?
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Broken bones hurt. The lining of the bone (periosteum) is rich with nerve endings
that can cause pain when inflamed; and the muscles surrounding the fracture go into
spasm to prevent movement of the fracture site, and this spasm may intensify the
Bones have a rich blood supply and will bleed when injured. This will cause swelling
and the blood that seeps into the surrounding tissue will also cause further pain. The
discoloration due to the blood can show up as dark red or purple bruise in the area of
the fracture site.
Because muscles and tendons may not be damaged, the person may be able to move
the injured extremity. For that reason, just because you can move the injured area,
doesn't mean it's not broken.
If there is damage to a nearby artery, the injury may be cool and pale (distal to the
injury), and if there is nerve damage, there may be numbness (distally).
When should I call a doctor if I think I have broken a bone?
Most broken bones require medical care but the urgency of that care depends upon
the type of fracture and the circumstances.
How is a broken bone diagnosed?
The doctor will take a history of the patient's injury, examine the injury, and look
for potential other injuries that may have occurred.
The skin surrounding the injured area is inspected to look for alaceration,
scrape, or skin tear.
The area of tenderness and swelling will be evaluated to identify the injured
The type of X-ray that is ordered depends on the specific injury.
6. Sometimes plain X-rays do not identify the injury. If the doctor is still concerned,
CT scan or MRI might be ordered.
What is the treatment for a broken bone?
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The initial treatment of a fracture begins with stabilization and immobilization. In the
field RICE (rest, ice, compression and elevation) may help make the patient more
comfortable and prevent the fractured bones from moving. Often the pain associated
with a fracture is due to spasm of the muscles surrounding the fracture site trying to
prevent movement. Splinting may help relieve some of that pain. Depending upon the
injury, EMS providers may consider traction to help with stabilization and pain
For non-open fractures, or other fractures that can be treated without emergency
surgery, the goal is to immobilize the injury to maintain anatomic alignment to allow
the bone to heal.
Bone heals in three stages.
Reactive stage: The blood clot that forms at the fracture site begins to organize
and the body's building blocks start to bridge the gap between the two ends of
the broken bone.
Repair stage: Specialized cells located in the outer lining of the bone
(periosteum), begin to form a lattice work or grids of cartilage and bone, called a
callus, which spans the fracture. More bone is laid down to provide strength to
Remodeling phase: Over the next few years, the body will attempt to resculpt
this mass of bone into it's original size and shape.
In the emergency department, walk in clinic, or doctor's office, the extremity is
usually splinted using a combination of soft padding, casting material (plaster,
fiberglass), and ace wraps. This splint is not circumferential like a cast, because a
fracture has the potential for swelling of the surrounding tissues, and if a tight cast
were in place, that swelling could cause complications including significant pain and
potential blood supply issues.
Once the patient is discharged, their instructions are to elevate the injury and ice the
area, even with the splint, to help decrease swelling and inflammation.
7. After a few days, once the initial swelling has resolved, a circumferential cast may
replace the splint and will be worn until the fracture is healed. The time frame for
healing depends upon the type of fracture and its location. X-rays may be used to
help determine when it is time for the cast to be removed.
Finger and hand fractures may be more complicated. The hand is a complex web of
tendons, blood vessels, and nerves that allow fine motor function. What might be
acceptable healing and alignment in an arm or leg may not be appropriate in a hand.
Some finger injuries need nothing more than a metal splint or buddy taping one
finger to another for support, while others will need surgery. The type of treatment
will depend upon the type of injury.
Most toe injuries heal very well own and need nothing more than buddy taping one
toe to another for support.
The treatment for rib fractures involves pain control so that the patient can take deep
breaths and allow the lung to expand beneath the injury site to prevent pneumonia.
Rib injuries are not wrapped or bandaged to help with pain control because this will
limit their movement, and prevent lung expansion. Because of this, rib fractures
generally take 4 to 6 weeks to heal and may cause pain throughout the healing
What about surgery for a broken bone?
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The decision to operate on a fracture depends upon the type of fracture, whether it
can heal in good alignment on its own, and whether other potential complications
Sometimes patients are taken to the operating room for a closed reduction (resetting
of the bone) and splinting of the fracture. When a fracture is markedly displaced and
misaligned, it may be too painful to move or manipulated the bone without an
If it appears that the fracture is unstable and cannot be held in place and in good
alignment with just a splint or cast, an open reduction and internal fixation (ORIF)
may be needed. An incision is made so that the bony pieces can be identified and
aligned. Metal plates and screws, wires or rods may be used to stabilize the fracture.
8. The hardware may be left in place forever or it may be there only temporarily until the
fracture heals. Hip fractures almost always require ORIF to allow the patient to heal
and regain the ability to walk.
Surgery may be required in situations where there is associated injury to arteries and
nerves and they need to be repaired or decompressed.
Open fractures often have to go to the operating room to be washed out to prevent
infection of the bone (osteomyelitis).