Broken bones
Introduction
A break or a crack in a bone is known as a fracture. Fractures can affect any bone in the body.
Bones can fracture in a number of different ways. A simple (or closed) fracture is a clean break to the bone that does not damage any surrounding tissue or break through the skin.
A compound (or open fracture) is when the surrounding soft tissue and skin is damaged. This kind of fracture is more serious as there is a higher risk of infection.
Healthy bones are extremely strong and usually able to withstand strong forces. However, if a force is too great or the bone is abnormal it can fracture.
As you get older your bones become weaker and you become more prone to falls and fractures. One in two women and one in five men will have a fracture after the age of 50.
Young children get different types of fractures, because their bones are more elastic. They also have growth plates at the ends of the bones, which can be damaged. Growth plates are the areas of growing bone at the end of long bones in children and adolescents.
Fractures are usually a result of an accident such as a bad fall or car crash. The time it takes for a bone to heal depends on the type of fracture, where it is and if it is an open or closed fracture. It is a gradual process and can take anything from a few weeks to a few months.
Types of fracture
Different types of fracture include:
- Transverse, a straight break across the bone.
- Oblique, a slanting break.
- Spiral, a winding break.
- Longitudinal, a break along the length of the bone.
- Comminuted, when the bone is shattered into several pieces. This is more common in serious accidents.
- Torus or buckle fracture, a fracture that occurs in children, when the bone deforms but does not crack. It is painful but stable.
- Greenstick fracture, which occurs in children when the bone partly fractures on one side but does not break completely because the rest of the bone is able to bend. Young bone is softer and more elastic than adult bone.
- Avulsion fracture, which occurs when a muscle or ligament that supports or is attached to a bone pulls on the bone, causing it to fracture.
- Compression or crush fracture, when the bone collapses. This usually happens in the spongey bone found in the spine.
- Fracture dislocation, when a joint becomes dislocated and there is also a fracture of one of the bones of the joint.
- Impacted fracture, when one fragment of bone is driven into another when the bone is fractured.
- Pathological fracture, which occurs in a bone that has already been weakened by a disease, such as osteoporosis, or by a tumour or cyst.
- Stress fracture, when a bone breaks due to repeated stresses and strains. It occurs mostly in the lower leg or foot bones of athletes.
- Hairline fracture, when the bone is only partially fractured. This can happen after a trip or fall and can be difficult to detect as the bone does not completely break.
^^ Back to top
Symptoms
The symptoms of a fracture depend on the bone affected and the severity of the injury, but can include:
- pain and swelling,
- bruising or discoloured skin around the bone or joint,
- the limb or part of the body being bent at an unusual angle (angulation),
- inability to move or put weight on the injured limb or part,
- a grinding or grating sensation or sound in the bone or joint (crepitus), and
- bleeding, if it is an open fracture.
A person who has fractured a bone may look pale and clammy and feel faint, dizzy or sick. This is usually due to the pain. These symptoms can also occur when large bones, such as the pelvis or femur (the bone in the thigh) break, causing internal bleeding.
Unless it is absolutely necessary, do not move a person with a fractured limb until a splint has been applied by a doctor or paramedic to prevent movement above and below the fracture.
If you think you may have fractured a bone, seek medical help immediately.
^^ Back to top
Causes
Causes of broken bones
Healthy bones are extremely strong, rigid and usually able to withstand strong forces. But if a force is too strong, a bone can fracture. Fractures are usually a result of a bad fall or car crash.
As you get older, your bones become weaker and you become more prone to falls and fractures. Young children are more prone to fractures because their bones are softer and they are more likely to have falls and accidents.
A bone fractures more easily if it is weakened by disease such as osteoporosis (which makes bones become thin and weak), by infection or by a tumour or cyst. This is called a pathological fracture.
Bones can also fracture as a result of repeated small stresses or strains. This type of fracture is known as a stress fracture and is common in athletes.
^^ Back to top
Diagnosis
Fractures are usually diagnosed from your symptoms, along with a physical examination by the doctor. They will also ask about your medical history and how the injury occurred. An X-ray confirms the diagnosis.
In some cases, a series of X-rays or an MRI or CT scan may be needed to look at a fracture more closely.
^^ Back to top
Treatment
Treatment of a fracture starts with lining up the ends of the broken bone so that the natural healing process can begin. Aligning the broken bone is known as reducing the fracture.
Fracture reduction is normally done under general anaesthetic (where you are asleep). Surgery may be used to realign bones or bone fragments or it may be done without surgery by manipulating or pulling the bone fragments (closed reduction).
Immobilisation
Once aligned, the ends of the broken bone must be held in the proper position while they heal. This is known as immobilisation. Different ways to do this include:
- Plaster casts or plastic functional braces to hold fractures in position until they have healed.
- Metal plates and screws, using minimally invasive techniques rather than large skin incisions.
- Internal steel rods, called intra-medullary nails, which are down the centre of long bones such as the thighbone and shinbone. In children, flexible wires can be used in the same way.
- External fixators. These devices resemble scaffolding lying outside the body. They can be made of metal or carbon fibre and have steel pins that pass into the bone directly through the skin, in order to hold the bones in place. It is called an external fixator as it is outside the body.
Immobilisation lasts between two and eight weeks, depending on the bone and any complications, such as infection or damage to the blood supply.
The healing process
Most broken bones heal successfully once they have been aligned correctly and immobilised.
During the healing process, bone cells called osteoclasts absorb any old or damaged bone, so that it can be replaced with new bone made by other bone cells called osteoblasts. New bone formed around a fracture is called callus. Callus forms on either side of the fracture and grows towards each end until the fracture gap is closed. Over time, the excess bone is smoothed off and the bone returns to normal.
The time it takes for a broken bone to heal fully depends on the age of the patient, the site of the bone affected and the type of fracture. Smoking can delay the healing of fractures.
In some cases, physiotherapy is needed after the bone has healed to help build up strength in the muscles and restore mobility in the injured area. Fractures near or through joints may result in the joint becoming permanently stiff or being unable to bend properly.
Compound and complicated fractures often require plastic surgery to repair the damage to the skin and soft tissue surrounding the bone or joint.
Slow-healing fractures
Fractures that are slow to heal are known as delayed unions. Those that fail to heal are called non-unions.
When bones do not heal, ultrasound therapy may be used. Low-intensity ultrasound, similar to that used to look at babies developing in the womb, is applied to the area of the break. This is usually done daily for a short amount of time. There is evidence that in some cases the energy the ultrasound transmits helps the fracture to heal. It is still being investigated as a therapy for delayed unions.
When fractures refuse to heal, a bone graft may be needed, although this is rare. A bone graft is when a natural or synthetic bone is transplanted, to stimulate the broken bone.
Scientists are currently researching the use of stem cells to heal fractures that otherwise fail to heal.
^^ Back to top
Complications
Malunion
If a fracture shifts or is not aligned properly it can heal in the wrong position. This is known as a malunion.
Growth disturbance
In children with fractures affecting the growing ends of bones, the normal development of the bone can be disrupted. As the child grows, this can lead to deformity of the limb.
Osteomyelitis
A compound fracture, where there is a break in the skin, can lead to infection of the bone or bone marrow. This can progress to a persistent infection called osteomyelitis.
Osteomyelitis requires treatment with antibiotics and careful management in hospital. Surgical drainage and curettage, a process where a spoon-like instrument (curette) is used to remove diseased tissue or marrow, may be needed.
Avascular necrosis
In some fractures, the bone can lose its blood supply and die. This is known as avascular necrosis. Bones most commonly affected include the scaphoid in the wrist, the humeral head in the shoulder and the head of the femur (thigh bone).
^^ Back to top
Prevention
There are two types of cells constantly at work in your bones: osteoblasts and osteoclasts. Osteoblasts build up new bone while osteoclasts break down old bone.
Up to our mid-20s, osteoblasts build strength into bones. But from the 40s onwards, osteoclasts take over and our bones gradually lose their density.
Bone loss is part of the natural ageing process, and fractures become more likely later in life.
Bone health is largely determined by genetics, but there are some external factors that have some influence. These include diet, exercise, alcohol consumption, body weight and smoking.
Diet
To develop and maintain healthy bones, it is important that you have enough calcium in your diet. Good sources are include milk, cheese, yoghurt and green leafy vegetables. Vitamin D, found in eggs and oily fish, helps the body to absorb calcium.
Exercise
Bones get stronger and denser with regular weight-bearing exercise. Weight-bearing exercise is where the weight of the body pulls on the skeleton, such as walking, running, aerobics and skipping.
It is particularly important that older people remain active, to help to reduce their risk of fractures.
Getting out of the house is important too. Sunlight acts on the skin to create vitamin D, which is also needed for healthy bones.
During the menopause
The female hormone oestrogen regulates the use of calcium in a woman's body. After the menopause, women produce far less oestrogen, so calcium regulation becomes harder.
Because of this, it is very important that women make their bones as strong as possible before the menopause.
After the menopause, the risk of osteoporosis can be reduced by:
- short, frequent sessions of weight-bearing exercise,
- giving up smoking,
- moderating alcohol consumption, and
- exposure to daylight and
- eating plenty of calcium, found in vegetables such as broccoli and peas and dairy products such as milk, cheese and yoghurt.
If you cannot get enough calcium from your diet, consider calcium supplements. See your doctor before you start taking these.
^^ Back to top
Thank you for your feedback.
The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.