dem bones

Hey doc is it broken or fractured? To a physician this is a moot question. I have never understood the misconception that fractures and broken bones are two separate entities. All broken bones are fractures.

The complexity comes in the large number of qualifiers attached to the word "fracture". Simple, compound, comminuted, spiral, oblique, pathologic, torus, Salter-Harris, Hill-Sachs, monteggia, colles, bartons and many other eponymous sobriquets are used to describe specific fractures of various bones.

Simple vs complex. A simple fracture is enclosed by the body's tissues. A compound fracture is one that has penetrated the skin and is therefore contaminated with bacteria. Comminution connotes the fracture is in more than two pieces. A crush fracture means that bone is in many small pieces.

Fractures in the bones of children are unique because the bones are still growing. The Salter-Harris classification is related to the extend of the damage to these growth areas. The scale runs from 0-6 ( originally 1-5); from no visible disruption of the growth plate to complete crushing of the growth plate. The higher the degree of the damage, the more likely the growth plate will not heal and allow continued growth of the involved bone. It is imperative that these fractures be recognized by the ER doc and appropriate referral made for treatment by an orthopedic surgeon.

Pathologic fractures occur in bones that have been compromised by a disease process. Osteoporosis, the loss of bone density that occurs as we age, is a common cause of these fractures. Cancers, especially of the breast and prostate gland, metastasize to the bones. The tumor thins the bones and fractures may occur with minimal trauma. Metabolic diseases, such as parathyroid gland dysfunction, can also weaken the bones. The "dowager's hump" is a form of pathologic fractures of the vertebrae that leave the female (can occur in men as well) with a severely curved spine.

Bones are well supplied with nutrient blood vessels and some of the larger bones contain marrow (places where new blood cells are formed). Fractures can therefore cause a great deal of bleeding into the surrounding tissues. Arteries can lie along long bones, and a fracture may lacerate the artery causing even more bleeding.

The four limbs of the human body contain fairly rigid compartments. These structures have "walls" of dense connective tissue, skin and bones. If a fracture in a compartment occurs, the swelling may lead to increased pressure that can damage the nerves, veins, and arteries that course through the compartment. The muscles in the compartment are also effected and leaking of muscle proteins can block the tubular structures in the kidney and cause kidney failure.

The mechanism that caused the fracture gives valuable information to the ER doc. The type of fracture is determined by the specific trauma involved. Stubbing a toe, twisting an ankle, falling onto a hand; all contain clues as to the type of fracture the ER doc will be treating. Falls, MVC's, assaults are potential sources of fractures.

Bones are well supplied with nerves that transmit pain sensation. Fractures hurt. The caring ER doc will give pain medication and limit the motion of the fractured bone to make the patient more comfortable. Compound fractures require treatment for potential infection; tetanus shots and antibiotics are employed to avoid a limb or life threatening infection.

ER doctors, PA's and nurses are always alert to the possibility that a fracture may be caused by abuse. If the fracture type is not consistent with the history of how the fracture allegedly occured, abuse must be considered. Most states have mandatory reporting laws. These laws put the onus on the ER staff to notify the appropriate authorities of their suspicions. I once treated an infant for a swollen thigh. An x-ray showed a spiral fracture. This type of fracture is caused by a twisting stress on the bone. The parent told me that baby had fallen off the changing table. I initiated a child abuse investigation. A series of x-rays of the child revealed multiple fractures in all four limbs in various stages of healing.

Be active, take your calcium, wear protective equipment for the activities in which you participate. The ER will be ready to diagnose and treat that break/fracture.