A fracture is where the continuity of the bone has been altered. Also often referred to as a break, these two terms are synonymous.
Below, Dr. Bryan Butler answers all your common bone fracture questions including causes, symptoms, and treatment options.
Bone Fracture FAQ’s
Causes of Fractures
Most fractures are caused by trauma or an injury. This can be low energy like a slip and fall, or a twisting motion such as slipping off of the curb and twisting an ankle. Causes can also be high energy from things like motor vehicle or motorcycle accidents. Some fractures are due to a weakening of the bone from chronic disease – these are called pathological fractures, and are most common in patients with high risk or known cancer diagnoses.
Pain, swelling, tender to touch, deformity with bending or angulation to the bone, inability to put weight (if lower extremity) or lift/carry (if upper extremity). If trying to diagnose at home, tender to touch on the “bone” itself is the most consistent thing to differentiate a bad sprain from a fracture.
Types of fractures
Fracture types are classified in several different ways:
- mechanism (traumatic, low energy, high energy, pathologic)
- whether open where the bone has poked out of the skin (old definition is compound) or closed where the skin and soft tissue is still intact
- location of fracture (long bone like a femur or humerus, near the joint like around the ankle or wrist, into the joint)
- xray finding type (oblique, spiral, transverse, comminuted (multiple pieces), avulsion)
- whether the fracture segments are line up (non-displaced) or shifted (displaced), or rotated/angulated.
Do all fractures need surgery?
No. Not all fractures need surgery.
The absolute indications for surgery are Open Fractures (fractures that have come through the skin), fractures where there is urgent damage to the blood supply or nerves to the extremity, and fractures that are associated with a dislocated joint (like a proximal humerus fracture with humeral head dislocation). There are then fractures that almost always get surgery, like hip fractures, displaced ankle fractures, fractures that are 100% shifted on xray. But even these can be treated non-operatively in certain individuals, although with lesser results. Ultimately, though, fractures that are displaced or shifted extensively, that are not lined up appropriately, or that extend into the joint surface with disruption of the joint surface, get offered surgery.
What type of surgery could fractures need?
Most fractures that need surgery get what is called an Open Reduction and Internal Fixation (ORIF). This is where an incision is made and the fracture is reduced, or lined up with clamps and instruments, and metal or titanium, sometimes carbon, plates and screws are used to hold the fracture together. Some fractures can be closed reduced and percutaneously fixed (CRPP) where the fracture is lined up with manipulation without incisions and either wires or screws or a titanium rod is placed through small incisions to keep the fracture together to allow for healing. Some fractures that involve the joint or are close to the joint, such as femoral neck fractures of the hip or proximal humerus fractures the shoulder, need a joint replacement. This is usually done in older patients who are lower demand and have a fracture near or into the joint.
What are alternative treatments to surgery?
Alternatives to surgery are using either casts, braces, or splints to immobilize the fracture to allow the fracture to heal on its own. This is usually associated with limited use and weight bearing or loading the affected extremity to allow for the bone to heal. We call this nonoperative treatment of the fracture. While surgery is avoided, sometimes this treatment requires more frequent doctor visits to make sure the fracture is staying aligned and/or changing of casts, as well as it might take more time for the fracture to heal with this approach.
How bad does a fracture need to be to require surgery?
The fracture has to be displaced and angulated significantly to have consideration for surgery. Each bone that is fractured has its own indications and rules to help decide whether surgery is needed. These rules have been studied with evidence based medicine to give guidelines on what can be acceptable to treat non-operatively. Some fractures, like avulsion fractures where a ligament has torn off a piece of bone, almost never get surgery, as they will heal fine without intervention. Whereas other fractures, like femur fractures, almost always get surgery regardless of if they are shifted because it is such a large bone.
Once I fracture a body part once, is it now prone to future fractures?
If fractures completely heal, both clinically (ie, without pain or tenderness) and radiographically (no evidence of a fracture line seen on xray), then the fracture is not at any higher risk of fracture in the future. If the fracture has not fully healed or has healed in a very angulated or rotated position, then it could be at risk for future breaks and or symptoms such as pain, functional loss, or deformity.
Common sense risk assessment is key to prevent fractures, based on the level of activity. If a patient is older and approaching late 50’s into 60’s, then there is risk of osteoporosis or osteopenia (especially in women), and a DEXA scan and calcium/vitamin D levels should be evaluated under the management of a primary care physician, as proper preventative measures could prevent low energy fractures from occurring.
Smoking cessation, avoidance of substance abuses, normal daily calcium intake, and staying fit and active are all good ways to maintain good bone health.
How long does it take for a fracture to heal?
Fractures in general can take up to 8-12 weeks to heal. Some fractures will be slow to heal (we call this a “delayed” union) and can take up to 6 months to heal, but this is rare. Usually, fractures are at high risk of not healing in the first 6 weeks, so most restrictions with activity, weight bearing, casting/splinting, boots, etc are in place for 6 weeks. Some fractures that involve weight bearing parts of the lower extremities, like fractures that involve the knee joint, will require patients to completely stay off the leg for 12 weeks. Age also plays in role in time to heal. Toddlers and adolescents can usually heal fractures in 4-6 weeks, whereas mature adults can take longer.
How long will it take to get back to my everyday activities?
This is variable based on the fracture. Simple fractures like a finger or toe fracture will require less time whereas wrist or shoulder fractures can take longer. Generally, we say with major fractures, especially those that required surgery, the goal is to be unrestricted by about 3 months, but also noting that while the fracture would have been healed by that time, it can take longer time to get all of the motion, function, and strength back. In really bad fracture cases, symptoms, although mild, can persist up to a year, and patients should understand that healing and functional improvement persists even after the fracture has healed.
Can a fracture result in a permanent impairment?
Yes. Some fractures that do not heal well or in the right position can have permanent impairment. Physical or occupational therapy is often needed to improve function and help lower the risk of impairment after treatment of a fracture.
How many times do I need to see an orthopedic doctor after the fracture happens?
Most fractures require visits and xrays up to time of healing, which is usually 12 weeks. Common visit time periods are 2 weeks after the injury, 6 weeks after an injury, and 12 weeks after an injury to evaluate and assess the progress of fracture healing. Sometimes, we see patients back quickly after the injury or first x-ray, a week later or so, if we are undecided if surgery is needed or not, mostly to see if the fracture will remain stable (well aligned). If it shifts early on, then surgery could be recommended even though initially non-operative treatment was decided.
Dr. R. Bryan Butler is an orthopaedic surgeon with an interest in specialized care for injuries of the Shoulder and Elbow. After earning his medical degree from the University of Maryland School of Medicine, he spent his residency at the University of Maryland Medical Center and R Adams Cowley Shock Trauma Center where he was involved in research, education, lectures, and served as Academic Chief Resident in his final year of residency. Dr. Butler continued his training at the Harvard Combined Orthopaedic Fellowship Program, internationally with the world renowned shoulder surgeon Dr. Laurent LaFosse, and received further sub-specialty training in Elbow Surgery at the Mayo Clinic in Rochester, Minnesota. Full Bio