Fractures & Trauma

A bone fracture is a medical condition in which a bone is cracked or broken. It is a break in the continuity of the bone. While many fractures are the result of high force impact or stress, bone fracture can also occur as a result of certain medical conditions that weaken the bones, such as osteoporosis.

The word “Fracture” implies to broken bone. A bone may get fractured completely or partially and it is caused commonly from trauma due to fall, motor vehicle accident or sports. Thinning of the bone due to osteoporosis in the elderly can cause the bone to break easily. Overuse injuries are common cause of stress fractures in athletes.

Types of fractures include:

  • Simple fractures in which the fractured pieces of bone are well aligned and stable.
  • Unstable fractures are those in which fragments of the broken bone are misaligned and displaced.
  • Open (compound) fractures are severe fractures in which the broken bones cut through the skin. This type of fracture is more prone to infection and requires immediate medical attention.
  • Greenstick fractures: This is a unique fracture in children that involves bending of one side of the bone without any break in the bone.

Fracture Healing

Our body reacts to a fracture by protecting the injured area with a blood clot and callus or fibrous tissue. Bone cells begin forming on the either side of the fracture line. These cells grow towards each other and thus close the fracture.

Medical Therapy

The objective of early fracture management is to control bleeding, prevent ischemic injury (bone death) and to remove sources of infection such as foreign bodies and dead tissues. The next step in fracture management is the reduction of the fracture and its maintenance. It is important to ensure that the involved part of the body returns to its function after fracture heals. To achieve this, maintenance of fracture reduction with immobilization technique is done by either non-operative or surgical method.

Non-operative (closed) therapy

comprises of casting and traction (skin and skeletal traction).

  • Casting
    closed reduction is done for any fracture that is displaced, shortened, or angulated. Splints and casts made up of fiberglass or plaster of Paris material are used to immobilize the limb.
  • Traction
    Traction method is used for the management of fractures and dislocations that cannot be treated by casting. There are two methods of traction namely, skin traction and skeletal traction.

Skin traction involves attachment of traction tapes to the skin of the limb segment below the fracture. In skeletal traction, a pin is inserted through the bone distal to the fracture. Weights will be applied to this pin, and the patient is placed in an apparatus that facilitates traction. This method is most commonly used for fractures of the thighbone.

Surgical Therapy

  • Open Reduction and Internal Fixation (ORIF)
    This is a surgical procedure in which the fracture site is adequately exposed and reduction of fracture is done. Internal fixation is done with devices such as Kirschner wires, plates and screws, and intramedullary nails.
  • External fixation
    External fixation is a procedure in which the fracture stabilization is done at a distance from the site of fracture. It helps to maintain bone length and alignment without casting.

External fixation is performed in the following conditions:

  • Open fractures with soft-tissue involvement
  • Burns and soft tissue injuries
  • Pelvic fractures
  • Comminuted and unstable fractures
  • Fractures having bony deficits
  • Limb-lengthening procedures
  • Fractures with infection or non-union

Rehabilitation

Fractures may take several weeks to months to heal completely. You should limit your activities even after the removal of cast or brace so that the bone become solid enough to bear the stress. Rehabilitation program involves exercises and gradual increase in activity levels until the process of healing is complete.

Foot & Ankle

The foot and ankle in the human body work together to provide balance, stability, movement, and Propulsion.

This complex anatomy consists of:

  • 26 bones
  • 33 joints
  • Muscles
  • Tendons
  • Ligaments
  • Blood vessels, nerves, and soft tissue

Ankle Fractures

The ankle joint is composed of three bones: the tibia, fibula, and talus which are articulated together. The ends of the fibula and tibia (lower leg bones) form the inner and outer malleolus, which are the bony protrusions of the ankle joint that you can feel and see on either side of the ankle. The joint is protected by a fibrous membrane called a joint capsule, and filled with synovial fluid to enable smooth movement.

Ankle injuries are very common in athletes and in people performing physical work, often resulting in severe pain and impaired mobility. Pain after ankle injuries can either be from a torn ligament and is called ankle sprain or from a broken bone which is called ankle fracture. Ankle fracture is a painful condition where there is a break in one or more bones forming the ankle joint. The ankle joint is stabilized by different ligaments and other soft tissues, which may also be injured during an ankle fracture.

Causes

Ankle fractures occur from excessive rolling and twisting of the ankle, usually occurring from an accident or activities such as jumping or falling causing sudden stress to the joint.

Symptoms

With an ankle fracture, there is immediate swelling and pain around the ankle as well as impaired mobility. In some cases, blood may accumulate around the joint, a condition called hemarthrosis. In cases of severe fracture, deformity around the ankle joint is clearly visible where bone may protrude through the skin.

Types of fractures

Ankle fractures are classified according to the location and type of ankle bone involved. The different types of ankle fractures are:

  • Lateral Malleolus fracture in which the lateral malleolus, the outer part of the ankle is fractured.
  • Medial Malleolus fracture in which the medial malleolus, the inner part of the ankle, is fractured.
  • Posterior Malleolus fracture in which the posterior malleolus, the bony hump of the tibia, is fractured.
  • Bimalleolar fractures in which both lateral and medial malleolus bones are fractured
  • Trimalleolar fractures in which all three lateral, medial, and posterior bones are fractured.
  • Syndesmotic injury, also called a high ankle sprain, is usually not a fracture, but can be treated as a fracture.

Diagnosis

The diagnosis of the ankle injury starts with a physical examination, followed by X-rays and CT scan of the injured area for a detailed view. Usually it is very difficult to differentiate a broken ankle from other conditions such as a sprain, dislocation, or tendon injury without having an X-ray of the injured ankle. In some cases, pressure is applied on the ankle and then special X-rays are taken. This procedure is called a stress test. This test is employed to check the stability of the fracture to decide if surgery is necessary or not. In complex cases, where detail evaluation of the ligaments is required an MRI scan is recommended.

Treatments

Immediately following an ankle injury and prior to seeing a doctor, you should apply ice packs and keep the foot elevated to minimize pain and swelling.

The treatment of ankle fracture depends upon the type and the stability of the fractured bone. Treatment starts with non-surgical methods, and in cases where the fracture is unstable and cannot be realigned, surgical methods are employed.

In non-surgical treatment, the ankle bone is realigned and special splints or a plaster cast is placed around the joint, for at least 2-3 weeks.

With surgical treatment, the fractured bone is accessed by making an incision over the ankle area and then specially designed plates are screwed onto the bone, to realign and stabilize the fractured parts. The incision is then sutured closed and the operated ankle is immobilized with a splint or cast.

Post-operative care

After ankle surgery, you will be instructed to avoid putting weight on the ankle by using crutches while walking for at least six weeks.

Physical therapy of the ankle joint will be recommended by the doctor. After 2-3 months of therapy, the patient may be able to perform their normal daily activities.

Risks and complications

Risks and complications that can occur with ankle fractures include improper casting or improper alignment of the bones which can cause deformities and eventually arthritis. In some cases, pressure exerted on the nerves can cause nerve damage, resulting in severe pain.

Rarely, surgery may result in incomplete healing of the fracture, which requires another surgery to repair.

Foot Fracture

The foot has 26 bones, and can be divided into 3 parts:

  • The hind foot is comprised of two bones, the talus bone which connects to the bones of the lower leg, and the calcaneus bone which forms the heel.
  • The midfoot is comprised of the navicular, cuboid, and three cuneiform bones.
  • The forefoot is made up of five metatarsal bones and 14 toe bones called phalanges.

The hind foot is separated from the midfoot by the mediotarsal joint and the midfoot is separated from the forefoot by the lisfranc joint. Muscles, tendons and ligaments support the bones and joints of the feet enabling them to withstand the entire body’s weight while walking, running and jumping. Despite this, trauma and stress can cause fractures in the foot. Extreme force is required to fracture the bones in the hind foot. The most common type of foot fracture is a stress fracture, which occurs when repeated activities produce small cracks in the bones.

Types of foot fractures

Foot fractures can involve different bones and joints and are classified into several types:

  • Calcaneal fractures: This type affects the heel bone and occurs mostly as a result of high-energy collisions. It can cause disabling injuries and if the subtalar joint is involved it is considered a severe fracture.
  • Talar fractures: The talus bone helps to transfer weight and forces across the joint. Talus fractures usually occur at the neck or mid portion of the talus.
  • Navicular fractures: Navicular fractures are rare and include mostly stress fractures that occur with sports activities, such as running and gymnastics, as a result of repeated loading on the foot.
  • Lisfranc fractures: This type of fracture occurs due to excessive loading on the foot, which leads to stretching or tearing of the midfoot ligaments.

Causes

Foot fractures commonly occur as a result of a fall, motor vehicle accident, dropping a heavy object on your foot, or from overuse such as with sports.

Symptoms

The common symptoms of a foot fracture include pain, bruising, tenderness, swelling, deformity and inability to bear weight.

Diagnosis

Your doctor diagnoses a foot fracture by reviewing your medical history and performing a thorough physical examination of your foot. Imaging tests such as X-rays, MRI or CT scan may be ordered to confirm the diagnosis. Navicular fractures can be especially difficult to diagnose without imaging tests.

Treatment

Treatment depends on the type of fracture sustained. For mild fractures, nonsurgical treatment is advised and includes rest, ice, compression, and elevation of the foot. Your doctor may suggest a splint or cast to immobilize the foot. For more severe fractures, surgery will be required to align, reconstruct or fuse the joints. Bone fragments may be held together with plates and screws.

Physical therapy may be recommended to improve range of motion and strengthen the foot muscles. Weight bearing however should be a gradual process with the help of a cane or walking boot.

Heel Fractures

The calcaneus or heel bone is a large bone found on the rear part of the foot. The calcaneus connects with the talus and cuboid bones to form the subtalar joint of the foot. A fracture is a break in a bone from trauma or various disease conditions. The types of fracture to the calcaneus depend on the severity and include stable fractures, displaced fractures, open fractures, closed fractures and comminuted fractures.

A fracture of the calcaneus is most commonly due to a traumatic event such as falling from a height, twisting injury, motor accidents, sports injuries and ankle sprain.

Fracture of the calcaneus is considered serious and can cause longstanding problems if not treated correctly. Stiffness and pain in the joint and arthritis are commonly reported risks of a calcaneal fracture.

The commonly seen signs and symptoms of calcaneal fractures are

  • Pain in the heel
  • Swelling in the heel
  • Bruises in the heel
  • Inability to walk or bear weight on the foot

The evaluation of the calcaneal fracture is done by imaging i.e., X-ray and CT scan. Based on the severity of the fracture, the doctor recommends the plan of treatment.

Calcaneal fractures are treated based on the type of fracture and extent of soft tissue damage.

  • Nonsurgical treatment
    • Rest, ice, compression, and elevation (R.I.C.E.) – is the most commonly used treatment option. Staying off (resting) the injured foot can heal the fracture to a great extent. Covering the affected area with ice packs over a towel reduces swelling and pain. Compression stockings and elastic bandages can also aid in healing the pain. Positioning the feet above the level of heart reduces swelling.
    • Immobilization – Casting the injured foot prevents the fractured bone from moving. Walking with the help of crutches is advisable to avoid bearing body weight until healing has occurred.
  • Surgical treatment
    • Open reduction and internal fixation – This surgery involves putting the bone fragments back together with metal plates and screws to reposition them and set them to normal alignment.
    • Percutaneous screw fixation – This is the best preferred treatment in cases where the bone pieces are large. The bone can either be pushed or pulled to set into place without making a large incision. Metal screws are then inserted and fixed through small incisions to hold the bone pieces together.

Rehabilitation

Irrespective of the treatment procedure, the patient is recommended to undergo physiotherapy and practice simple exercises regularly to help restore function. This would help the muscles to gain flexibility and after complete recovery, the patient can resume their daily living with normal activities.

Lisfranc (Midfoot) Fracture

Tarsometatarsal joint refers to the region found in the middle of the foot. It is also called as Lisfranc joints. It is a junction between the tarsal bones (group of seven articulating bones in the foot) and metatarsal bones (a group of five long bones in the foot). A deformity in the tarsometatarsal region can be due to arthritis and traumatic motor accidents.

Tarsometatarsal arthritis is characterised by pain, functional impairment and midfoot instability. The appearance of bruises and swelling on the dorsal side of the midfoot are the commonly observed symptoms. The doctor will first examine the physical condition of the foot by inspection and palpation (feeling with hands). You may be advised to get an X-ray taken. You might also be sent to get a CT or MRI scan done to provide more information about your condition.

The early stages of injury can be treated by analgesics, steroid injections and by wearing special footwear or casts. Tarsometatarsal joint fusion is recommended if all the non-surgical procedures fail to show efficacy in treating the injury.

  • Fellow of the Royal Australasian College of Surgeons
  • Fellow of the Australian Orthopaedic Association
  • Australian Medical Association
  • Royal North Shore Hospital
  • British Orthopaedic Foot & Ankle Society
  • American Orthopaedic Foot & Ankle Society
  • Australian Orthopaedic Foot & Ankle Society