Adult Fractures (Part 2 of 5) - Myles Clough, MD

Dr. Sechrest: Now I think we’re all used to seeing the compression fracture in the thoracic spine from osteoporosis. Does osteoporosis affect the whole skeleton the same? Are we just seeing the compression fracture in the spine because that’s where they show up first? Are these folks still at risk of ankle fractures, tibia fractures, femur fractures, all the other fractures that we talked about? Or are there some specific fractures that tend to occur more?

Dr. Clough: Well, they are at risk of fractures in any area if they are subjected to the sort of force that, in a younger and stronger bone, would not cause a spiral fracture of the tibia or a fracture of the femur, yeah, they are at greater risk. But there is a common pattern and the fractures that occur very commonly in osteoporotic patients are fractures of the hip, as you say, fractures of the spine where the spine compresses, fractures of the wrist, ankle fractures, and I those are probably, well, fractures of the shoulder as well. So that if you see or experience as a patient an osteoporotic fracture of any sort, maybe you’ve got the dowager’s hump, a little old lady curled over with progressive collapse of the spine, that means that she has osteoporosis and that means that she’s at greater risk than somebody who doesn’t have that problem for a wrist fracture, a disabling life threatening hip fracture or fractures of the shoulder, say, if they have a fall. It’s a sign that they should have their osteoporosis treated.

Dr. Sechrest: Yeah, I think one of the big changes over the last decade, and with orthopaedists, I think all of us tended to sort of treat the fracture and assume that somebody else was responsible for treating the osteoporosis. I think there’s been a big movement amongst orthopaedists who say if you see a wrist fracture in a 50 year old woman then you need to really be aggressive and say is there a significant treatable osteoporosis and, if there is, let’s get that started. Either we need to do it as orthopaedists, or we need to make sure that that patient is plugged into a physician that will take responsibility for that and actually treat that osteoporosis.

Dr. Clough: In some fracture clinics now there is a osteoporosis nurse, administrative person, who has got just that job of making sure that the patient who is identified by the fact that they’ve had a fracture and the fact that it’s an osteoporotic fracture is going to be plugged into a system to make sure that they’re treated not just for the fracture but for the osteoporosis as well.

Dr. Sechrest: I think osteoporosis is one of the most common pathologic fractures we see and we tend to think of that but there are others.

Dr. Clough: Oh yes, there definitely are.

Dr. Sechrest: A huge list of others. Can you talk with us a little bit about some of the more common ones and what you, as a patient, should think if they have a fracture they should think about having their physician make sure they check?

Dr. Clough: You know, I’m not sure it’s the patient’s responsibility. I think this is the doctor’s responsibility. The pathologic fracture through bone that is not osteoporotic, but is pathological, generally shows an abnormal pattern on x-ray. There’s essentially a hole in the bone. The bone itself has got weaker because of that hole, and has fractured essentially through the remaining bone, and that’s a pattern that should show up on x-ray and should be recognized. I think what the patient has to understand is that if that has occurred, then there are going to be some more tests done to find out why they had a hole in the bone. A hole, of course, isn’t really a hole, it’s usually a deposit of some sort. It’s an area of the bone that doesn’t have normal bone in it so it doesn’t show up on x-ray, but it usually has tissue or cells of some sort, and these could be cells from a distant cancer, and that’s probably, in the elderly, the commonest problem for pathological fractures. In children, and younger people, there are a number of benign noncancerous growths that can form in bone and make them weak, and I think it’s the responsibility of the doctor to find out which of all of these possibilities they are, and the patient’s code of aspect is to understand that if you have a pathological fracture then there are going need to be further tests, perhaps biopsies, and perhaps further x-ray tests to discover what type of pathological fracture you have here.

Dr. Sechrest: I would say the take home message is that if you’re a patient who’s had a fracture, and it doesn’t make sense that there was not enough energy to create a fracture in normal bone, that should concern you and your physician, and it behooves you to figure out why is that occurring.

Dr. Clough: Well, yes. If you are otherwise a fit, young, healthy person and you step down off a step and you have a fracture, then you perhaps need to talk seriously about looking for a reason for that bone breaking.

Dr. Sechrest: Let’s move on to symptoms, symptoms of fractures, and I think everybody knows that when you break a bone it hurts.

Dr. Clough: Absolutely.

Dr. Sechrest: You’ve gone through some of the reasons why it hurts. Let’s talk about some of the other symptoms that maybe aren’t so apparent to patients that they may experience, and some of them can be ominous in the sense that they should pay attention to those symptoms. So let’s talk a little bit about symptoms.

Dr. Clough: First of all, can I talk a little bit about pain, because pain does need to be understood. There are a number of reasons why a fracture hurts. Pain comes from nerves and we have to understand that. The nerves supply or grow in long bones and they’re also in the skin, the muscle, and the other soft tissues. When you break a bone you tear the nerves and that’s one reason it hurts. But you also stretch the other tissues and make them swell and that’s another reason why it hurts. So the pain that comes from broken nerves in the bone settles down quite quickly because those nerves heal up fairly, fairly soon, and if you don’t tease the fracture, if the fracture is at rest, those nerves are not going to be particularly active and so you’re not going to get a lot of pain from the broken part of the bone unless the bone is actually still moving. The remaining pain comes from disturbed circulation, swelling, stretching, damage, and inflammation in the soft tissue surrounding the area and that’s where the pain comes from, and that’s why people ask or are puzzled that the pain continues for quite a long time after the fracture has been treated.

Dr. Sechrest: I think the other thing we ought to bring up, and that is the whole concept of the evolution of pain and why pain is there. There’s a lot of folks who would argue that pain serves a very useful function in that case. If you need to allow this bone to heal, if you’re a caveman, and you’ve just broken your ankle, then you need to allow this bone to heal and, from an evolutionary standpoint, the way that that was done is that it hurts and it hurts until it is safe, in some ways, for you to move on that bone. So that, in some ways, there is this evolutionary reason for pain to occur and why it takes longer for a fracture to become less painful than it does for a simple cut or something in the skin.

Dr. Clough: Yes, there are some fascinating fossils. There’s one dinosaur fossil that had 27 different fractures, all of them healed, and so healing is not something you really need doctors for, but the pain mechanism, as you say, prompts you to keep that area still and keeping it still is a prerequisite for healing. So don’t disregard pain and don’t even think of pain as your enemy. Pain is a sign that you should keep that area at rest until it evolves into something a lot more comfortable.

Dr. Sechrest: Well, let’s talk about some more symptoms of fractures that, like I say, are a little bit more ominous than just pain. Things that we, as orthopaedists, begin to worry about when we see these symptoms occur, and we begin to think about different treatments for fractures and maybe complications that we need to pay attention to.

Dr. Clough: Well, we did discuss earlier the possibility of a wound. So that if there’s a wound in association with a fracture then that already moves you into the possibility of having an open fracture. So that’s one other symptom, if there’s a bleeding wound from where you’ve been broken, that’s a very serious problem, and the others that you are referring to – numbness, pulseless or cold legs, and intense swelling. So if you have a situation which the limb is swelling and becomes rigid and tight and very, very tender, then you’re at risk of a condition called compartment syndrome in which the muscle will die unless there isn’t an urgent decompression of that area and a release of the pressure as well. If you have a pulseless, or a cold limb, or a limb in which you can’t feel your fingers or toes, that suggests that the nerve to that area has been interfered with or damaged or that the blood supply of the hand or foot has been damaged, and that again is a symptom that the doctors will pay a lot of attention to, because if you’ve damaged an artery and it isn’t repaired then the chances of you losing your foot or your hand are very high.

Dr. Sechrest: You know, a lot of patients think that once these bones begin to break and go through the tissues that arteries and nerves are always damaged. I think we find that we’re always amazed that a fracture can look so jagged, the fracture looks like it can do some damage, and it’s uncommon to have actually an artery, a large major artery or a large nerve, damaged. They tend to get out of the way pretty well and they’re pretty resilient, so I don’t think patients ought to just assume that every time they break a bone they’re going to damage one of these structures because it’s actually uncommon.

Dr. Clough: Yes, and I think you’ve come back to evolution there. If it wasn’t rare, if any dinosaur that had broken a bone or torn an artery, it’s unlikely that that dinosaur would have survived to have progeny. So the patterns of common fractures tend to cause the bones to move in directions where they don’t damage the arteries, or to put it another way, the arteries have found a route where they’re out of the way of common fractures, I think. I can’t prove that, of course, but I think that’s probably what happened.

Dr. Sechrest: Well, this probably segues into a discussion about diagnosis and when a patient should sort of say, “Well, is that an ankle sprain or is that potentially a fracture that I need to go and get an x-ray?” Because I think a lot of us, you know, we fall on an outstretched hand, we’ve got a swollen wrist, we’ve think we’ve sprained it. We don’t know whether to go to the doctor and get an x-ray in western medicine or in the western world, I think, everyone presents themselves and sort of says, “I need an x-ray for this” and that’s sort of very common. But I think that there are a lot of things that we do miss and a lot of things that people assume that they don’t have a fracture, that they may have a sprain and it goes on to be a very complicated fracture and is much more serious than they really think. So let’s talk a little bit about the diagnosis and, as a patient, understanding when they should present themselves to a physician and get it checked out.

Dr. Clough: I don’t think a patient should basically present themselves and say, “I must have an x-ray”. I think they should present themselves if they’ve had a significant injury, if they’ve had a sudden event which caused pain and particularly disability, then they should present themselves, and if the doctor thinks they should have an x-ray, well, good. They should have an x-ray. But don’t second guess that because I think that there are times when you have an ankle sprain that you don’t need an x-ray. There are only quite few times when, if you have an ankle sprain, you shouldn’t ask for some professional help. So I would say have a low threshold for presenting to ask a doctor what’s happened, but don’t, more or less, say, “I must have an x-ray”. You were referring to fractures that are commonly not diagnosed early and I think one of the commonest is a wrist fracture in the scaphoid. This is a little bone in the wrist that is quite commonly injured and you can go on using your wrist quite well, even with a broken scaphoid bone, and as a result it often does not come to medical attention until months after the original injury sometimes years and sometimes people go on to have a lot of trouble because of that. So particularly in the wrist area but, as you say also in the knee and the ankle, if you can still use the joint, you can still walk on it, you can still move it, it doesn’t mean you haven’t got a fracture. So if you’ve had pain, swelling, and bruising, I would go and see a doctor.

Dr. Sechrest: Now, you as an orthopaedic surgeon, when you’re faced with a patient who presents with a potential fracture, how do you start? How do you get to the bottom of what’s going on?

Dr. Clough: Well, the first thing I do is ask about the accident. How did this happen? I try to go into some detail about the event because then you get an understanding of the type of forces that might have been applied. Now sometimes nobody knows what the event was, but there are often witnesses so if somebody is brought in from a road traffic accident there’s often people who’ve said this patient was in the back of the car and was retained by a seatbelt or was not and thrown 50 feet from the point of impact, so you get an understanding of the type of energy that’s involved. Then you look at things. Obviously if a bone is out of alignment then you know that it’s broken. If there’s a lot of pain and bruising and swelling in a certain area then you’re very suspicious that there will be a fracture there. If moving the area of the limb or moving the hand or foot distal to the potentially injured area is painful, then that is another indication that that area should be carefully examined and x-rayed. Now the examination, I don’t really do a lot. I touch gently and say, “Does it hurt?” and usually it does, so I don’t think it’s really important to push hard. In the days before x-rays, the cardinal signs of a fracture were pain, loss of function, and what they called ‘crepitus’. Crepitus means crunching. So one has this ghastly thought of medieval doctors moving broken limbs around to discover whether the bone was actually, you know, grinding on one another, and I don’t think that’s happening anywhere in the world these days.

Dr. Sechrest: You know, it’s interesting when I was a medical student I was actually taught how to diagnosis a fracture with a stethoscope.

Dr. Clough: Yeah?

Dr. Sechrest: And you can actually put a stethoscope at one end of the bone and tap on the other end of the bone and there’s a definite change if you have a fractured bone versus a solid bone, and it was one of those things that may date back to the medieval times.

Dr. Clough: I have done that reasonably recently with a hip fracture, because hip fractures don’t even show on x-ray, but you can tell the difference between the sound that travels up and down the bone from the good side to the bad side.

Dr. Sechrest: A couple of other interesting points that we really ought to draw attention to and one is about the history. Orthopaedics is probably the one field that really tries to understand the mechanics or the physics of what happened during the injury and people wonder why we’re doing that, but all of these fractures have common patterns based on what we consider mechanism of injury and if we can get a very good description of how the fracture, or how the injury, occurred we can tend to have a pretty good idea of what type of a fracture we’re going to see on x-ray, or MRI scan, or whatever technique we use, so it’s one of those things that’s unique to orthopaedics. I think that we tend to focus on physics, the physics, the mechanics of how something happened.

Dr. Clough: It is, taken also back into the historical treatment, the treatment of fractures in the days before we operated on them was to reverse the mechanism of injury so that if you felt that the fracture had occurred because of compression and twisting, well, you pulled and twisted the other way. So understanding, as you say, the physics of the injury was also related to the type of treatment that you thought you might have to do.

Dr. Sechrest: Yeah, and I think that’s still true today.

Dr. Clough: It’s still true. Of course it is.

Dr. Sechrest: I think any time we do a cast or a reduction we are understanding the forces not only that cause the injury but also the forces around that fracture that are being brought to bear by muscles, tendons, and the ligaments and that sort of stuff. I mean we use all those things to actually straighten bones and that sort of stuff.

Dr. Clough: That’s actually true.

Dr. Sechrest: I think the other piece is that people tend to think that all we do is look and get an x-ray and I think your point about “Well, I don’t like to push and torture people” necessarily, but there’s still some useful information that I can gain from actually palpating, figuring out where the tenderness is and those things are so important about the function of the soft tissue. Is that nerve working? Do I have a situation where the blood flow has been disrupted and do I need to deal with that? So it’s not just simply rush in, take a look, send patients to x-ray. We actually have to evaluate patients.

Dr. Clough: I agree with you completely. The examination is often more to do with the function of the hand or the foot downstream from the injury and therefore the implication is what has been injured as well as the bone. So that part of the examination is much more critical than pushing on the fracture itself. So when you are lying in bed with a broken bone and being asked to move your toes and people are more interested in your toes than your thigh where you know the injury is, that’s why. It’s not because they aren’t aware of the site of the injury, it’s because they want to be sure that the arteries and nerves that go past your thigh, past the break, into the foot, are working well.