Orthopaedic surgeons spend much of their time fixing things that become broken.  As opposed to many other medical specialties that focus primarily on illness and disease, a general orthopaedist spends a significant portion of his time dealing with injury.  One of the staples of orthopaedic practice is fracture management. 

Even though fractures are exceedingly common in orthopaedic practice and everyone has heard the term, there is often times little lay-person agreement on the definition.  A fracture is a break in the continuity of bone.  A common question posed to the orthopaedist is “is it broken or just fractured”.  Although a “break” is not a very precise medical term, it is generally thought to be the same thing as a fracture.

There are 206 bones in the body, all of which can be broken.  The bones that fall within the scope of an orthopaedic surgeon include the extremities and sometimes the vertebral column.  The fractures of the bones of the head are treated by head and neck surgeons.

There are literally multi-volume textbooks dealing with different types of fractures in both adults and children.  But there are some common themes that can be briefly explored in this column.

Since a review of the anatomy of the entire skeleton would seem to be a bit lengthy (and boring) to present here, lets skip to the clinical features of fractures.  There are five commonly used fracture signs.  Of course not all of these signs are present in every case, they can serve as a rough guide to the clinical evaluation of fractures.

The first is obvious deformity.  If there is a crook in the arm that usually isn’t there, it is probably fractured. Of course not all examples are this blatant, it is possible to see some fairly striking deformities following a fracture.  But keep in mind that there may be a subtle deformity or none at all.

The second fracture sign is discoloration.  Unlike the first this sign is fairly vague.  It is indeed possible to get discoloration from injuries other than a fracture.  However, fractures do often cause a dark local discoloration.

Another sign is point tenderness.  This is to be differentiated from generalized tenderness.  Someone who bruises their arm might be tender over a large area.  However, if there is a fracture there will likely be a point of increased tenderness over the portion of the bone that is fractured.

One of the most obvious signs of fracture is pain.  There are very few if any painless fractures.  The level of pain experienced with injury is often what prompts people to seek medical attention.

Swelling is another important sign of fracture.  Many, though not all fractures, swell in the post-injury period.  Any significant swelling following injury should be evaluated by a doctor.

The final clinical fracture sign is crepitus.  This is found when the fracture area is palpated and a feeling of grinding is present.  This represents the ends of the bones rubbing together.  Obviously, its not a good idea for lay people to attempt to manipulate a suspected fractured bone in order to elicit crepitus.  However, this may be found incidentally.

The definitive diagnosis of a fracture is made radiographically.   All bones that are suspected of being broken should be evaluated with X-ray.  Even if the clinical diagnosis of a fracture is obvious, the X-ray allows the orthopaedist to classify and categorize the fracture in order to make treatment decisions.  The threshold to X-ray a bone in order to determine if it is broken should be fairly low.

After a fracture is diagnosed, the treatment depends on an incredibly large variety of factors.  However, the overriding principle in fracture management is immobilization.  Although there are exceptions to the immobilization rule, most fractures are treated either with a splint, cast, or are immobilized surgically.  The determination of which treatment is appropriate should be made my an orthopaedic surgeon. 

If you suspect that you may have fractured a bone, even if it is only a suspicion, you should promptly seek the opinion of a doctor.  Delays in the treatment of some fractures can significantly worsen the prognosis.