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Bones Fractures

When a bone is broken

A bone fracture is a medical condition in which a bone is cracked or broken. If too much pressure is put on a bone than it can stand, it will split or break. If the broken bone pokes through the skin, it is called an open or compound fracture. In children incomplete fractures are frequent, in which the bones bend or buckle instead of break. The most commonly fractured bones are long bones (such as humerus, ulna, radius, femur, tibia and fibula). In some susceptible individuals, the spinal and pelvic bones can also get fractured, as a result of accident or falls.

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    How do I know if it’s broken?

    Sometimes it is hard to tell a dislocated joint from a broken bone, but generally you can recognize a broken bone noticing these signs:

    • An out-of-place, deformed or misshapen limb or joint
    • Swelling, sometimes bleeding
    • Bruising, warmth or redness
    • Severe pain
    • Tingling and numbness
    • Broken skin with bone protruding
    • Limited mobility or inability to move the limb

    What are the most common causes?

    The most common causes are falls from a height, injuries or accidents.

    Fractures are very common in childhood, as children play games and sports, jump, ride bicycles, run down the stairs and so on. The harder they play, the harder they fall. But some children have an inherited condition called “osteogenesis imperfecta” that makes their bones more fragile and susceptible to breaking. Also, neuromuscular disorders, renal diseases, diabetes and growth hormone deficiency may raise the risk of fracture in children.

    How do I know when my child is in pain?

    Your child may self-report pain, or you can observe it through her/his behaviour. For your child, it can be very painful to be touched or pressed on the injured limb. He/she can’t probably move it, and cannot bear any weight on it. Persistent crying is a common sign of pain in an infant, but it may also happen that your child doesn’t cry or respond. She/he may also faint or lose consciousness. Chest pain may indicate a broken rib. In all cases, try to reassure your child and keep her/him still and calm. If you suspect a fracture seek medical help immediately, or take your child to the nearest hospital emergency department if it’s possible.

    Who can help us in case it’s broken?

    Seek medical care right away, if you suspect your child has a fracture.

    In some very serious case, your child may have injured the head, the neck or the back: keep your child lying down until medical help arrives. In less serious injuries, you can apply on the injury a cold compress or an ice-pack wrapped in cloth. Do not apply ice directly on the skin. Leave the injured limb in the position you find it. It can be necessary for you to cut clothing off with scissors to prevent your child from having more unnecessary pain. Then you can place a soft padding around the injured part, and something firm (for example a board or rolled-up newspapers, etc.) next to the injured part, and long enough to go past the joints and below the injury. Fix it loosely with first-aid tape or wraparound bandage until medical care arrives. Don’t allow your child to eat anything, in case surgery is needed.

Bone fracture healing: how it works

Let us start from the basics: what are bones made of? The main component of a bone is bone matrix, which is a mixture of a fibrous protein called collagen and an inorganic compound mostly made of calcium and phosphate. All bones have an outer surface called periosteum, a very thin membrane with nerves (that cause pain) and blood in it. The compact bone is the smooth and very hard part of the bone: it’s what we see when looking at the skeleton. The spongy bone is lighter than compact bone, but still very strong. The inside parts of a bone are hollow, and they are filled with a kind of jelly called bone marrow.

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    What’s the difference between Kid bones and Adult bones?

    • Your baby has tiny hands, little feet, small limbs… an overall tiny body. As he/she grows up, everything becomes gradually bigger, including the bones. An infant has about 300 bones at birth; while growing, they fuse together to form the 206 bones that an adult has. Some of your baby’s bones are totally made of a special, soft and flexible material called cartilage; some others are partly made of cartilage. This cartilage is replaced by hard bone matrix as the bones reach their full size. By the time he/she is about 25, this process will be complete: the bones are as big and long as they will ever be. All together they form the skeleton, that is light but also strong and very resistant.
    • Children have open growth plates (called epiphysis) located at the end of the long bones. This is the area where the bone grows. Injury to the growth place can cause limb length discrepancies or angular deformities.
    • Small children are more likely to have incomplete fractures, that go partially through the bone, because their soft bones - which are still growing - often bend or buckle instead of completely break.

    How are the human skeleton’s bones classified?

    The bones of a human skeleton are classified in two major types: the axial skeleton and the appendicular skeleton. Axial skeleton has about 80 bones and appendicular skeleton has 126 bones. The main functions of the skeleton are to give shape to our body, provide attachment for muscles and produce red blood cells.
    The longest, largest and hardest bone is the thigh bone, also known as femur:

    • It is located between the knee and the hip
    • It makes up one-fourth of an individual overall height
    • It is a weight-bearing bone
    • It is very light in weight, but it is considered stronger than concrete
    • It is connected with the hip by a ball and socket joint that allows the freedom of movement.

    How many types of bones are there?

    There are 5 types of bones in the human body:

    • Long bones (i.e. Femur, Humerus and Tibia) which provide length to the body, support weight, facilitate movement and shock absorption.
    • Short bones, which provide support and stability with little movements (i.e. Carpals, Tarsal, Metacarpal, Metatarsal, Phalanges)
    • Flat bones, which provide protection to our vital organs, being a base for muscular attachment (i.e. Scapula, Sternum, Cranium, Pelvis and Ribs)
    • Irregular bones, which protect the internal organs and have a complex shape (i.e. Vertebrae, Sacrum, Mandible)
    • Sesamoid bones, short and irregular bones which provide protection to the tendon (i.e. Patella “the knee cap”, Pisiform).

    How does fracture healing work?

    Fractures heal at different rates, depending on the age of the child and type of fracture, but in general a child’s bone heals faster than an adult’s one, due to some differences in the bone structure. For instance, in children the periosteum is thicker, stronger and more active to better supply oxygen and nutrients to the growing bones, and this helps in case of fracture. Its inner part contains very vital cells able to produce new bone. So, if an injury or an accident unfortunately occur to your child’s bone, these cells are able to renew and remodel the broken bone. There is also a surgical operation called osteotomy in which a bone is cut on purpose by the surgeon to readjust or correct the bone’s alignment.

Types of fracture & treatment options

There are several types of bone fractures that may occur in children, including for example:

  • Greenstick or Buckle – an incomplete fracture in which the bone bends or buckles without completely breaking, frequent in small children
  • Open (or Compound) – the fractured bone breaks the skin
  • Closed (or simple) – a fracture that doesn’t break the skin or outer tissues
  • Comminuted – a fracture of three or more relatively small fragments
  • Displaced – the bone cracks completely in many pieces that move out of alignment
  • Transverse – a fracture that goes across the bone’s axis
  • Spiral – a fracture which runs around the axis of a bone
  • Oblique – a fracture which goes at an angle to the axis

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    What are the most frequent treatment options?

    The most frequent treatment options for bone fractures are:

    • Splint or Plaster Cast
    • Open reduction with internal fixation (ORIF)
    • Open reduction with external fixation (OREF)
    • Closed reduction with external fixation (CREF)

    The needed treatment will depend on the type of fracture.

    What’s the main differences among these treatments?

    • Splint and Casting are non-surgical options. They are mostly used in case of incomplete fractures (these fractures can often heal with just a splint) or closed, standard fractures (that commonly require a cast). Always follow your doctor’s instructions completely.
    • Open reduction with internal (ORIF) and external fixation (OREF), and more rarely together, are options which require surgery. ORIF is a recommended surgical procedure in case of complicated fractures not able to be realigned (reduced) by casting, or in case the long-term use of a cast is not desirable or indicated. The surgeon will operate your child under general anaesthesia, and will apply metal rods, screws or plates to repair the bones, that will remain in place under the skin after surgery. OREF is a surgical procedure which involves the use of an external device to support the bone and hold it firm in the correct position while it’s healing. The fixator is connected to the bones with bone screws, commonly called pins, and will be removed when healing is achieved. This procedure is recommended in case of quite complex fractures that cannot be repaired using open reduction with internal fixation.

    Who decides the best treatment options?

    The treatment your child needs will depend on the type of fracture, age, overall health and medical history. Each child is different and your orthopaedic surgeon – a doctor specialized in conditions related to bones health, ligaments, tendons and muscles – will discuss with you the necessary and best treatment for your child’s fracture. Your surgeon will also share with you your child’s recovery plan, and will be near you along the entire treatment to ensure the healing is proceeding as intended.

    What to expect after surgery, in case of surgery with external fixator?

    In case your child’s limb has been realigned with the use of an external fixator, your surgeon will give you an estimate of how long your child’s recovery will take, as it depends on every specific situation: type of fracture/s, child’s age, overall child’s health and other co-factors. During the healing process, it’s important that your child stays active and starts mobilizing as soon and safely as possible: playing, going back to school, keeping on his/her daily routines. When back home, your child should meet other children and friends, enjoying their company to overcome the initial stress and limitations, and always following the instructions provided by the surgeon and hospital staff.

    In case of treatment with external fixator, why is pin-site care so important?

    The pin-site is the area of skin crossed by pins or wires of the external fixator: it has to be checked carefully every day, and kept constantly clean to prevent infections at your child’s limb. It’s very important that you follow exactly the instructions provided by your surgeon and hospital staff.

    When will the hardware be removed?

    The hardware will be removed from your child’s limb when the surgeon is completely satisfied with the alignment and consolidation of the bone. It can also happen that your child needs to wear a cast for a short while after the fixator frame has been removed.

Resources

Building healthy bones can be obtained adopting a healthy nutritional and lifestyle habits in childhood, to help prevent osteoporosis and fractures later in life. One of the best ways to encourage healthy habits in your children is to be a good role model yourself. Children watch us, and our habits have a strong influence on theirs. The two most important lifelong bone health habits are proper nutrition - a varied and balanced diet with the right amount of the essential elements plus calcium and vitamin D - and physical activity.

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    What do the first aid steps include in case of bone fracture?

    In case of bone fracture, you should:

    • Call immediately for medical care
    • Keep your child still and calm
    • Support the injured limb with a pillow or sling
    • Check your child’s airway or breathing
    • Control your child’s blood circulation: press firmly over the skin beyond the fracture site, it should first blanch white and then pink up in 2 seconds
    • If skin is broken, it should be treated to prevent infections. If possible, rinse lightly the wound to remove visible dirt and cover with sterile dressing
    • If needed, immobilize the broken bone with a splint: these may include a rolled-up newspaper, cardboards or strips of wood. Immobilize the area both above and below the injured bone.
    • Apply ice packs wrapped in cloth to reduce pain and swelling
    • Prevent your child’s shock. Lay her/him down, if possible with elevated limb about 12 inches-30 centimeters higher than the heart. Do not move your child in case of head, neck or back injury
    • Treat bleeding placing a dry clean cloth over the wound to dress it
    • Pain relief may be needed: paracetamol may help to reduce pain. Follow dosage instructions given by your family doctor.

    Don’t:

    • Don’t move your child unless the broken bone is stable
    • Don’t move a child with a suspected injured spine, head, neck
    • Don’t move a child with injured hips, pelvis, upper leg, unless absolutely necessary
    • Don’t attempt to straighten a bone
    • Don’t apply heat in any form. Heat increases swelling and pain
    • Don’t allow your child to eat anything, in case surgery is needed.

    Which are the exams for a correct diagnosis?

    An X-rays is generally used to diagnose the type of fracture and whether or not the bones are in line (if there is a displacement or not). Although X-rays reveals most fractures, including subtle fractures in skeletally immature children, in some cases (for instance, occult physeal fracture) the fracture detection may be improved by using magnetic resonance imaging (MRI) or computed tomography (CT or CAT scan).

    Does physiotherapy count for my child’s bone healing?

    Physiotherapy exercises are very important for your child’s limb healing. Physiotherapy makes sure that his/her bones are surrounded and supported by healthy, strong muscles, and his/her joints go on functioning well, preventing permanent joint stiffness. These exercises must be constantly practised, under the supervision of a qualified physiotherapist.