Introduction

Fractures and broken bones are the same thing. A fracture may be a crack as thin as a hair, a severing of bone into two or more separate pieces, or a shattering of bone into many small, scattered pieces. A fracture may cause discomfort so slight that the person does not think the bone is broken. Or a fracture may cause extreme pain. In older people, a fracture may have long-lasting effects, because recovery after an injury is slow.

In older people, the most common fractures involve the hip, bones of the spine (vertebrae), shoulder, and wrist. But any bone can be fractured. Fractures that make walking impossible, usually hip fractures, are the most serious.

Causes

A bone breaks when the amount of force placed on the bone is greater than the strength of the bone. A large force can break even the strongest bone. But very slight force can break a weak bone.

In older people, most fractures result from a fall. Fractures may result from fainting or an injury, as may occur in a motor vehicle accident.

As people age, bones become less dense and thus become weaker. A large decrease in bone density is called osteoporosis. In people with osteoporosis, a fracture may result from a fall (even when gentle) or from the moderate stress of ordinary movement (as when getting out of a chair).

Other disorders weaken bones and thus make fractures more likely. Paget's disease and overactive parathyroid glands (hyperparathyroidism) weaken bones throughout the body. These disorders may also cause a bone to heal more slowly after a fracture or to shorten as it heals. Other disorders, such as infections and cancer, may weaken bones in specific places. These disorders can prevent a bone from healing or from healing as quickly after a fracture.

Symptoms

Most fractures cause pain immediately. They usually continue to hurt, especially when a person uses the injured body part. The area around the fracture is often tender to the touch. When the fracture occurs, a snap is sometimes heard. A limb or joint may be obviously out of place.

Moving the injured part may cause a painful, grating sensation. Movement may be limited or impossible. If a bone in the leg breaks, standing is usually painful or impossible. Injured tissues around the fracture begin to swell. Bruises appear, usually a few days afterward but sometimes within several hours.

Swelling often damages the skin. It can cause itching, flaking, scaling, or blisters. Sometimes swelling in a broken limb continues to worsen. Swelling can become so severe that it prevents blood from flowing out of the limb to the heart. Then, blood flow to the skin of the limb is reduced. As a result, pressure sores may develop and may take weeks or months to heal.

If swelling becomes so severe that it also cuts off blood flow to the limb, the pain in a broken limb suddenly becomes much worse. The limb may feel numb or cool. These symptoms should be reported to a health care practitioner immediately. This disorder is called compartment syndrome. Older people are more likely to have severe swelling after a fracture.

Some symptoms develop later. Some result from the treatment of fractures, for example, from immobilization with casts or other devices or from bed rest. An immobilized limb becomes weak and usually loses muscle tissue. If a joint is not moved for a long time, it may become permanently tight and stiff. This condition is called a contracture.

If people are confined to bed after a fracture, they may develop difficulty breathing and chest pain. These symptoms may result from a blood clot that has formed in a vein of the leg, broken off, traveled through the bloodstream, and blocked an artery that carries blood to the lungs. This blockage, called pulmonary embolism, is life threatening.

Pain may persist when the pieces of a broken bone do not grow back together (a condition called nonunion). Pain may also persist when the bone grows back crooked or incompletely (a condition called malunion). Fractures may extend into a joint, often resulting in permanent arthritis and stiffness in the joint. These problems are more common among older people.

Diagnosis

Doctors examine the injured area and the area around it to check whether bones are out of place and whether the person can move nearby joints normally. They also look for swelling, changes in color or temperature of the limb, tenderness, and skin damage.

X-rays are taken. They can detect most fractures. X-rays taken several days later may detect a fracture that could not be seen earlier. If x-rays do not detect a fracture but a fracture seems likely, computed tomography (CT) or magnetic resonance imaging (MRI) may be done. These procedures can detect a less obvious fracture and can usually provide more information about a fracture.

If the diagnosis is still unclear or cancer is suspected, bone scanning is done several days after the fracture. This procedure involves injecting a small amount of a radioactive substance, which can be detected by a special scanner. This substance collects in bone that is starting to heal and thus can identify a fracture.

Doctors ask questions to determine what caused the fracture—a fall, fainting, or an injury. They also ask whether the person has any disorders that can weaken bone. Tests to determine the strength and density of bone (such as dual-energy x-ray absorptiometry, or DEXA) are often done. With this information, doctors may be able to recommend ways to help prevent other fractures.

Prevention

One important way to prevent fractures is to prevent falls. Wearing appropriate shoes (with firm, nonslip soles and low heels) may help prevent falls. Exercising to improve balance and muscle strength, having vision checked regularly, and modifying the home to make falls less likely can also help. Treating disorders that can cause fainting and preventing accidents may help prevent fractures. For example, people should always wear a seat belt whether they are driving or riding in a car. Older people can also learn techniques to improve their driving.

Another way to prevent fractures is to keep bones strong. Consuming enough calcium (in foods or in supplements), regularly doing weight-bearing exercises (such as walking or playing tennis), and not smoking can help keep bones strong.

Treatment

If a person may have a broken bone, a doctor should be called so that treatment can be arranged. If possible, first aid techniques are then used to prevent movement of (immobilize) the injured part. Immobilization helps prevent the ends of the broken bone from moving and causing further injury and pain.

For most bones, a splint or sling may be used. A splint consists of a firm object strapped to an arm or a leg. For example, a magazine or stack of newspapers could be wrapped around the arm with ribbon or tape. A sling is a bandage or any piece of cloth used to support the forearm. The bandage is wrapped under the arm and tied behind the neck. Most fractures involving a wrist, an arm, or a shoulder can be immobilized with a sling. Usually, a person with one of these fractures can be taken by car to a hospital. For a person with a fracture of a hip or leg, an ambulance is usually called.

Before and after treatment by a doctor, pain and swelling can be reduced by keeping the injured limb above the level of the heart and by applying ice. These measures are particularly important during the first 2 days after the injury. An ice pack or a bag of crushed or chipped ice can be placed in a plastic bag on a thin towel over the injured part. Ice can be applied every hour while the person is awake. The skin should be checked regularly for numbness, swelling, and redness to make sure the cold is not damaging the skin. Elevating the limb can also help reduce swelling.

Longer-term immobilization: For most fractures, doctors immobilize the injured part for several weeks or months to give the fracture time to heal. Some fractures (such as rib fractures) cannot and do not need to be immobilized.

Before immobilization, doctors sometimes need to align fragments of broken bone (a procedure called reduction). This procedure helps prevent angled bone fragments from pressing against the skin and improves blood flow to the hands or feet. Also, precisely aligning fragments of broken bone within a joint helps prevent arthritis from developing in the joint. Before the procedure, measures are taken to relieve pain: A local anesthetic is injected near the injury, pain relievers are given intravenously, or a general anesthetic is used, depending on the location and severity of the fracture.

A cast, splint, brace, or sling can be used to immobilize the injured part. Sometimes surgery is needed. The goal is to sufficiently support and immobilize a broken limb while enabling the limb to be used as much as possible.

Casts are the strongest and most rigid devices. They are used when fragments of broken bone might move around. Casts may be made of plaster or fiberglass. All casts are lined with soft cottony material to protect the skin from pressure and rubbing. Because older people take longer to recover from an injury, they may have to wear a cast longer than younger people.

After bone fragments start to grow together, a cast may be replaced with a removable splint or brace. Or the cast may be split into two pieces, re-lined, and fitted with Velcro straps so that the cast may be taken on and off. Removable devices make bathing and skin care easier. Also, the joint can then be stretched and moved periodically so that it is less likely to become stiff.

Using the least restrictive and shortest cast or splint and being able to put it on and take it off as soon as possible are particularly important for older people. The skin of older people is more likely to be damaged by casts and nonremovable devices. Older people are encouraged to regularly check their skin near the ends of the casts or other devices. Also, immobilization is more likely to cause joints to stiffen and muscles to weaken in older people. As soon as possible, older people should take the cast or splint off for a short time each day so that they can move the joint.

If a cast cannot prevent the broken bone fragments in a wrist, forearm, or lower leg from shifting or collapsing, a technique called external fixation is often used. Strong metal pins are inserted into the normal, unbroken bone on either side of the fracture. The pins protrude through the skin. They are clamped to a frame of rods outside the arm or leg. External fixation holds the broken bone fragments securely. It makes skin care possible and enables the person to move and use the rest of the arm or leg. After the bone heals, the rods are unclamped and the pins are removed.

If a broken arm or leg is immobilized with a cast or with pins and rods, many daily activities (especially walking) are difficult. The immobilized limb feels heavy and awkward. It can interfere with balance or get in the way. Some people with an immobilized leg need to use a walker. Most people with an immobilized leg need the help of a physical therapist to learn to walk safely and comfortably.

If the part of limb below the fracture becomes unexpectedly painful, numb, or cool (possibly indicating compartment syndrome), immediate treatment is needed to prevent tissues from being damaged. Usually, the cast is split open and removed. In severe cases, external fixation may be needed temporarily to immobilize the fracture. Once the swelling goes down and tissues heal, a new cast is applied.

See the sidebar Caring for a Cast.

Traction: Traction is rarely used. It requires bed rest for a long time, which can cause many problems. Traction is used only when other treatments, including surgery, are not possible or are too risky. For example, traction is used when a person is too frail to undergo surgery safely or when there are too many bone fragments for a cast. Traction involves applying a gentle, steady pulling action, which may align bone fragments. Traction is done with adjustable bands wrapped carefully around the limb, cords, a pulley (with not more than a 5-pound weight attached), and a metal frame placed over or on the bed.

Surgery: For some fractures, surgery is best. When possible, surgery is done within a day or two. With surgery, broken bones can be precisely aligned and metal implants (such as rods and pins) can be inserted, usually permanently, to hold the broken fragments securely together. Metal rods may be inserted into the broken bone. Or metal plates may be attached to the side of the broken bone with screws. These procedures are called internal fixation, because all of the metal implants used are inserted within the body. Metal implants made in the last 15 years do not interfere with magnetic resonance imaging (MRI). Most do not set off security devices at airports. Some large implants near the skin's surface set them off.

If the upper arm bone (humerus) breaks at the shoulder joint or the thighbone (femur) breaks at the hip joint, repair is often impossible. In these cases, surgery is needed to replace the broken part of the bone that is part of the joint.

Surgery is needed for hip fractures, which otherwise would require months of bed rest and traction to heal. Surgery may enable people to walk within a few days. Surgery also results in a better recovery. Surgery may also be needed for fractures that have not healed after many months of treatment and for fractures in bone weakened by cancer, which heal poorly.

Some circumstances make surgery inadvisable. If osteoporosis has greatly weakened the bones, metal implants may slip out of position. For people who have certain disorders, especially heart, lung, kidney, or liver disorders, surgery may need to be delayed. People who take a drug that makes the blood less likely to clot (anticoagulant) may need to discontinue the drug and delay surgery until the drug's effects wear off and blood can clot normally.

Prevention of problems after treatment: Drugs may be used to control pain during the several weeks needed for healing. For most fractures of the vertebrae or pelvis, treatment includes bed rest for a short time. Reduced activity and bed rest can cause problems, particularly for older people. Problems include loss of muscle tone and tissue, stiff joints, pulmonary embolism, urinary tract infections, pressure sores, confusion, and depression. Hospital staff members take steps to prevent these problems. To the injured person, these steps may seem bothersome or too demanding, but they are necessary for a good recovery. For example, to prevent pressure sores, staff members may periodically change the person's position in bed. Areas of skin that are in contact with the cast, especially areas in which bones are close to the skin (such as the heels), are padded and inspected frequently for any sign of pressure sores.

Rehabilitation: Rehabilitation, particularly physical therapy, may help a person regain the ability to function or to compensate for abilities that were lost. For most fractures, rehabilitation should begin immediately. Doing range-of-motion and muscle-strengthening exercises daily helps keep joints flexible and increase strength. Range-of-motion exercises involve moving a joint in all directions possible. Diligently doing the recommended exercises leads to a better recovery. Family members and caregivers can provide encouragement. If muscles are too weak for the person to move them or if bone fragments could be easily displaced, a therapist moves the muscle. However, ultimately, the person must move muscles against gravity or resistance (using weights) to regain full strength of an injured limb.

While the fracture is healing, a person should also exercise the uninjured joints, particularly other joints in the injured limb. A joint within the cast cannot be exercised until the fracture has healed sufficiently and the cast is removed. When exercising the injured joint, the person should pay attention to how it feels and avoid exercising too forcefully. Also, the person should avoid staying in one position too long.

How long rehabilitation is continued depends on the type and location of the fraction and on the person's general condition. Rehabilitation may take only a few days or require weeks of intensive rehabilitation. Some people need only a few visits for rehabilitation. People who need intensive rehabilitation may have to stay in a rehabilitation facility or nursing home.

Outlook

Fractures heal in stages. How quickly a fracture heals depends on how severe and how large it is, where it occurs, how the broken bone is used, and how strong the bone was before the fracture. Some small fractures in the hands heal in a few weeks. But large fractures in the legs may take many months to heal (partly because leg bones must bear the person's weight).

In older people, bones heal about as quickly as they do in younger adults. However, older people often have weaker muscles, less dexterity, and poorer balance. Also, in older people, stiffness tends to develop after an injury. As a result, many older people have difficulty making the needed adjustments after a fracture. For example, they may be unable to use crutches, so they must wait until a broken leg is healed enough to bear full weight before they can walk. Thus, older people often take longer to return to their daily activities than younger people.

For a while after a fracture has healed, some discomfort may be felt when the injured part is used. For example, after a wrist fracture, gripping forcefully may be painful for up to 1 year, even though the person may be able to use the hand after about 2 months. Also, when the weather is damp, cold, or stormy, the injured part may ache and feel stiff.

After a fracture heals, most people can function reasonably well. However, some older people never recover strength and flexibility in the injured part. For them, daily activities, such as eating, dressing, bathing, and walking, may continue to be difficult or impossible.