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Sticks and Stones May Break My Bones

When I started this digital adventure, I did it for the following reasons:

  1. It’s fun.
  2. And professionally fulfilling. I’m trying to fight the good fight as far as preaching the accurate word about evidence-based pediatric practice, and do some medical and patient education on a macro scale.
  3. I have more opportunities to hear about and meet THE MOST adorable and hilarious kids.

So today, this is about 1, 2, and 3; but mostly 3.

Christopher, age 8 and a twin, came in to our urgent care office to see one of my colleagues the other day because he had fallen down and injured his forearm. He’s a tough guy and then some, but when I say that his arm hurt, I mean it really hurt. He could barely move it.

My partner Dr. Dave Mathison knew right away that Christopher needed an X-ray. Look at this film:

broken arm x-ray

You don’t have to be a pediatric radiologist or even a medical professional to know that that bone is broken, right?

What I DO know as a medical professional is that those kinds of fractures are fairly common and heal up great (happy for Christopher and all those other kids who break their arms). So now we have a broken forearm, specifically— the mid-shaft of the radius.  WHAT NOW?

This is really what I want to address today, and it will hopefully relate to #2 above. What happens after a fracture? Lots of people like to say, “oh you have to ‘set it’” or “follow up with an orthopedic surgeon” but they don’t really understand what that means.

Fractures can be described in several different ways, and the description is really crucial to understanding the treatment plan:

  1. Closed or open.

An open fracture means that there is an opening in the skin overlying the fracture site. Doesn’t matter how big or small (relatively); if there’s a break in the skin that’s more than a scratch, that’s an open fracture and most of those need antibiotic treatment to prevent infection.

  1. Displaced or non-displaced.

A non-displaced fracture means that the bone is still in relatively good alignment around the fracture site: that there’s just a simple crack in the bone. There’s a fracture called a “buckle fracture” and it means that part of the bone around the edge just simply cracked and “buckled.” Most of the time a non-displaced fracture needs no manipulation or setting (we call this “reduction”); just simple support with a splint or cast helps protect the bone as it heals on its own.

  1. Simple or comminuted. (25 cents!)

A comminuted fracture has multiple bone fragments at the fracture site. Many times these are visible on the X-ray as a bunch of bone chips at the site of the break. Kind of a whopper to look at, honestly. A simple fracture is just that: simply one break.

This refers to the degree of break— really, the angle (in degrees) of the fracture fragment. This number is important because some fracture types require more invasive intervention if the break has a high degree of angulation.

Lots to absorb here, but what’s the purpose of all these fancy descriptive words?

As I alluded to earlier, some fractures need absolutely ZERO reduction, and some have to be fixed in the operating room. And then there are those in-between, like Christopher’s.  Depending on the bone broken (elbows are notorious for requiring the OR), the degree of misalignment, and a few other variables like the age of the patient or how open a fracture is, the management is dictated by what each case looks like.

Sometimes the broken bone needs a little “help” lining back up, and by “help” I mean it needs to be pushed on and adjusted to get back into proper position. There’s no way I can dress up that statement. What we generally do is give a nice dose of pain medicine to make the child as comfortable as possible and then manually reposition the bone so that it’s lined up for optimal healing once casted. Everyone tolerates this procedure differently: some easily, some less so. I encourage everyone to partner together in this situation so that the child can be made as comfortable as possible: this involves pain medicines, distraction measures, and calm caregivers to make this work well.

If a reduction is performed in the acute care setting and not in the OR, another X-ray is typically taken afterwards to demonstrate improved alignment of the fracture. It’s usually done after the fiberglass splint/cast has been placed.  Here’s Christopher’s:

broken arm left side x-ray

If you compare this X-ray to the first one, see how the bones look better positioned?

They don’t have to be exactly lined up in order to heal beautifully: the human body is a magical thing and bone cells repair and regenerate pretty well. Once the post-reduction films are completed and satisfactory, the acute care visit is complete and specialty follow up by an orthopedic surgeon usually is forthcoming. These fractures can be pretty sore, so giving ibuprofen, keeping the extremity elevated, and protecting the splint or cast (and not getting it wet) are important parts of after-care.

If you do all this right, then you’ll end up a super hero just like mighty-man Christopher. Nothing, not even a forearm fracture, will stop this cute guy from working his wonders. #3 from the top of this post- adorable kid exposure- accomplished. Don’t you think?

little boy in cast with broken arm