Fracture

© Reed Group

Risk: Individuals of advanced age, individuals exposed to falls and/or objects falling on them, those who experience a motor vehicle accident, as well as individuals involved in high-risk activities performed with high-impact or at high-velocity are at increased risk for fractures.

Individuals who participate in sports activities that involve running, jumping, and sprinting have a higher risk for stress fractures, since the force of each running step is at least three times that of the individual's body weight (DeLee). Individuals with a genetic predisposition to rigid, high-arched feet (pes cavus), those with a leg length discrepancy that imparts greater stresses to the longer leg, those with a hallux valgus deformity or a longer second ray (Morton's foot), and those with pronounced hip external rotation are also at increased risk for a lower extremity stress fracture (DeLee).

Individuals with inflammatory bowel disease have a 40% greater incidence of fracture than the general population (Berstein 759).

Older individuals with a heightened risk of fracture include those with history of prior fracture or a fall within the previous 12 months and those with low bone mineral density, quadriceps weakness, or postural instability. Women with osteoporosis are 1.6 times more likely to sustain a fracture than men with osteoporosis, although 50% of all fractures occur in individuals without osteoporosis (Nguyen).

History: Fractures are either the result of a traumatic event or repeated stress to a bone in the body. In cases of trauma-related fractures, individuals may describe an injury, such as a fall or an object falling on or striking them. The individual may report having heard a cracking sound at the moment of fracture, and may be unable to bear weight on the affected limb if the fracture occurred in the lower extremity. However, the ability to move and use an injured body part does not exclude the possibility of a fracture. In cases of stress fractures, the individual may not remember a specific injury, but there usually is a history of recent activity to which the individual is not accustomed or a repeated activity that stresses a bone (e.g., distance running). It is important to obtain a thorough history, including medication use and previous injuries.

Physical exam: Individuals may have obviously misshapen (deformed) bones, swelling, pain and/or lack of feeling (decreased sensation) near the area of a fracture. Visual examination may be diagnostic in cases where the deformity is obvious. Touching the area (palpation) reveals pain or tenderness over the area. There may be decreased sensation beyond the fracture. Swelling and bruising (ecchymosis) usually is present. Joint looseness (laxity) and changes in range of motion may be evident.

Tests: Plain x-rays are used to determine the presence of a fracture, the severity of the fracture, and the position of the fragments. X-rays generally include the joint above and below the injury site. Subtle (occult) fractures and some stress fractures may not be visible on x-ray exam for up to 2 weeks after they occur. Suspected but hidden fractures (occult fractures) of the scaphoid bone in the wrist are undetectable on plain x-ray 60% of the time (Brydie 296). CT scans and/or MRI may be needed to further define the fracture and its effect on surrounding joints. Electromyogram and angiography may be required to evaluate damage to nerves and blood vessels. A bone scan may show a subtle fracture, such as a stress fracture that is not easily recognized on plain x-rays.

The goal of rehabilitation of fractures is to restore functional abilities of the individual (Salter). The duration and type of rehabilitation treatment required following a fracture are related to the associated soft tissue involvement, as well as the location and type of fracture and the method of stabilization (Chapman). Protocols for rehabilitation must be based upon stability of the fracture and fracture management (operative, nonoperative).

Rehabilitation emphasizes restoring full range of motion, strength, proprioception, and endurance, while maintaining independence in all activities of daily living (Bucholz). Cold and other modalities may be used in controlling pain and edema (Salter). The individual should be encouraged to continue functional activities to prevent complications of inactivity and bed rest. Depending on the stability of the fracture, range of motion exercises of the adjacent joints may be started immediately and progressed to strengthening exercises as indicated (Chapman).

Bone healing may occur within 6 to 20 weeks; however the bone strength and the ability of the bone to sustain a heavy load may take up to several years (Chapman). Once healing has occurred, the individual may resume full activities of daily living. Resumption of pre-injury status is the goal, with consideration of any residual deficit. The treating physician should guide the resumption of heavy work and sports; it is important to instruct the individual not to overload the fracture site until the bone has regained its full strength.