Fractures

--What are fractures and why do they happen?

A fracture is a crack or break in a bone. Many people think that a break is worse than a fracture or the other way around, however the word fracture is just the medical term for a bony crack or a break.

A bone of normal quality or strength will fracture due to unusual or excessive forces or stresses going through the bone. This can happen during an accident or trauma, or a sudden change in activity. Abnormal bone such as  osteoporotic bone or bone weakened by another medical condition, can fracture when normal forces or stresses are applied. These can happen with only minimal trauma or have no known cause. Although osteoporotic bone can fracture more easily, it should heal within the normal time frames.

Although causes of fractures vary with age and activity, falling is a major cause of fracture in all age groups. This can happen through sport, accidents or activities of daily living.

--Why are they a concern?

A fracture will initially cause varying amounts of pain and swelling, treatment lasting for six weeks or in some cases, several months. This can be a great inconvenience and can have a huge impact on your life, potentially affecting your work, ability to carry out daily activities, to care for others and to function normally. More severe fractures can have long-term impacts. In a small proportion of cases it can be the reason for career change or in extreme cases you may no longer be able to work or return to your home.

In Australia, osteoporotic fractures occur every 3-4 minutes, with someone admitted to an Australian hospital every 5-6 minutes with these fractures. Once you have had a fracture you are 2-3 times more likely to have another, which is a significant burden to the individual and society.

Fracture prevention can take many forms: parental supervision in children’s activities, risk assessment and behaviour modification as people reach adulthood, health and well-being programs and falls prevention and osteoporosis identification and management. Physiotherapy can play a part in all of these programs.

--What are the different types of fractures?

There are many types of fractures:

Simple undisplaced fractures are the most common type of fracture where the bone is broken but is still in good position. Greenstick fractures are where the bone is broken on one side. These are commonly seen in children, as the bones are more flexible. Buckle fractures are also common in children where the bone only creases or buckles.

Treatment for all the above fractures usually involves just a cast or a splint.

A fracture caused by repetitive stress is called a stress fracture and when they are caused by an underlying disease they are called pathological fractures.

More complex fractures include displaced fractures, where the bone is out of position and needs to be realigned; open fractures, where the skin is broken by the fracture or injury; fracture dislocations where the fracture has caused the joint to dislocate and comminuted fractures are where the fracture is in several pieces. These more complex fractures usually require a procedure by an orthopaedic specialist to realign and stabilise the fracture. Sometimes metal plates, screws or nails are used and occasionally a joint replacement may be required.

Less commonly, if a person already has a metal plate in their bone or an artificial joint, they may sustain a fracture at the end of the metal or joint replacement. This is called a peri-prosthetic fracture.

--How do I know if I’ve fractured a bone?

A fracture causes pain and swelling in the surrounding area. If you’ve had a fall or injury and you think you may have a fracture, you should seek professional help so you can be examined and have x-rays taken. If the fracture is not obvious on x-ray, you may be sent for a CT or MRI to help with diagnosis. If the pain is severe and the limb looks deformed, it is best to report to a hospital emergency department.

If you have a sprain it will improve over the next day or so but if fractured the pain will persist. In the case of ankle injuries, if you are unable to weight bear you should seek attention.

--Should I be worried?

Fractures are very common injuries and heal in the expected time without complication. Ensure your doctor or physiotherapist has explained your fracture and treatment to you. If the doctor feels there may be any weakness in your bones, they can organise simple tests for bone density, as well as calcium and vitamin D levels, assessing you for osteoporosis. Osteoporosis is more common in adults and therefore children are not investigated for weak bones until they have had multiple minimal impact fractures.

Osteoporosis is the result of the removal of ‘normal’ bone accompanied by decreases in replacement of bone with ageing. Osteoporotic bones heal normally but signal increased risk of future fractures. In Australia osteoporosis affects one in two women over the age of 60 and one in three older men. There are evidence based management guidelines to prevent refracture in this population.

--How can physiotherapy help with fracture?

Physiotherapists can assist you throughout the management of your fracture, at the time of diagnosis, treatment and rehabilitation to recovery. If they suspect you may have a fracture at the initial assessment, or if you fail to progress as anticipated, they can send you for an x-ray to check for evidence of a fracture.

If you have a fracture they can apply an appropriate cast, splint or brace after speaking to your doctor or before you go to your doctor for review. Your physiotherapist will also advise you how to reduce your swelling and care for your cast, splint or brace and give you exercises to prevent other joints from becoming stiff. They will give you warnings about what to look out for regarding increased pain, swelling, throbbing or pins and needles and how to alleviate these symptoms and any problems that may develop. If the injury involves your ankle or leg, they can provide you with walking aids such as crutches and will instruct you in their correct use.

While your fracture is healing your physiotherapist may adjust or change your cast or splint as required and monitor how you are managing with your injury and exercises. When it is time for removing your cast or brace, they can give you tailored exercises and advice on what to expect in this early stage of rehabilitation. As you improve, they will progress your exercises to help a full recovery.

--How effective is physiotherapy for preventing fractures?

Physiotherapists help people remain active and encourage healthy lifestyles. Remaining active and completing weight bearing exercises have been shown to decrease the incidence of fractures in people suffering from osteoporosis. There is a clear link between improving strength and balance and falls reduction, which ultimately reduce fractures.

--How effective is physiotherapy for my recovering after a fracture?

Physiotherapy has a large role to play in helping you to make a faster and more complete functional recovery from your fracture. During your treatment, you may have been immobilised in a cast, splint or brace, which can cause stiffness in the joints near the fracture. Even if not placed in a cast or brace you may have had restrictions to your movement, such as a shoulder fracture, or weight bearing ankle fracture, which causes both joint stiffness and loss of muscle strength.

Some research has shown that early movement under the supervision of a physiotherapist in some specific fractures can help prevent some of the stiffness that may develop during the fracture healing process.

--What can I do at home?

It is important that you practise your individually prescribed exercises that you have been given by your physiotherapist. If you are attending a falls prevention program, you should practise these exercises too. The exercises need to be done regularly with increasing repetitions and must be exactly as instructed, cutting corners will delay your progress. Do regular short sessions of exercises rather than one long session where fatigue may cause you to do the exercises incorrectly.

The exercises may be designed to help you regain full range of movement in your joints and regain the strength in your muscles that can be weak after injury and immobilisation. As you progress in your exercises you can do them more frequently. At the appropriate time you may be directed to use small weights to further increase muscle strength. Restoring full range of movement and strength will allow you to return to normal function more quickly.

Balancing exercises may be given to help recovery and to prevent future falls. These exercises should always be practised in a secure and safe way, having a wall nearby if required to assist you.

--How long until I recover?

Recovery time will vary with the severity of your injury, especially if you have multiple areas of your body affected. In the case of a simple wrist or ankle fracture, the basic healing of the fracture will occur in the first six weeks. You then need to regain your range of motion and strength, and during this time there may be restriction on some activities like contact sport. It is anticipated that you will be back to most activities by 12 weeks, but it may be 6-12 months until you feel that you have made a complete recovery.

With more complex fractures of the spine, pelvis and long bones such as the shin bone (tibial shaft) or femur (thigh bone), it may take 12 weeks to initially heal and a further 6-12 weeks to return to normal activities.

In the vast majority of fractures people make a complete recovery with no residual effects.