What is a fracture?

A break in the continuity of a bone. Fractures like most injuries come in many forms from relatively minor 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 path to healing 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

Cracks appear in bones which are likened to those in metal that have endured repetitive stress.  A Stress Fracture is an example of this type of injury and is usually the end result of a continuum that begins with bone strain and stress reactions that occur within the bone with overuse. 

3.  Pathological

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

Classification of Fractures

Open Vs Closed

Fractures have many classifications depending on the type of fracture or break and whether it involves other tissues.  For example an open or compound fracture occurs where the skin or body cavity is broken. On the other hand if the overlying skin remains intact the fracture is said to be closed or a simple fracture.

Stable Vs Unstable

When you have an investigation such as an X-ray or Bone Scan they wish to ascertain 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

This classification is more of a continuum than either one or the other. At one extreme a complete fracture implies that the bone has broken into two or more fragments.  This is the opposite to an incomplete fracture where the lining of the bone (periosteum) is still intact eg. greenstick fracture.  

Healing depends on

• Type of bone 
• Amount of movement at the fracture site (consider classifications of fractures) 

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 mopped 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 unwanted bone is carved away so that the bone resumes a relatively normal shape. 

Timeframe

The amount of time before healing will vary between individuals and will be affected by age, constitution, blood supply, type of fracture etc. 

Physiotherapy Management of Fractures 

• Muscle Balance Assessment and Exercise: 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 Focus on Movement Physiotherapy Centre 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. 

If you have any questions regarding this information or your physiotherapy management, please don’t hesitate to call SportsCare and Physiotherapy O’Connor on 02 6247 0912