Upper and lower limb fractures: from the cast to modern fixation

How to recognise a fracture and what to do

• Severe pain, swelling and bruising after a fall or a blow.
• Not being able to move the limb or put weight on it.
• Deformity or abnormal movement.

Keep the limb still as it is, without trying to straighten it. Apply ice and go for an X-ray. If there is a wound over the fracture, numbness or pale fingers or toes, call 166 (or 112).

Cast or surgery: how we decide

The decision rests on three things: whether the pieces of bone have shifted, whether the fracture reaches into a joint, and what the person needs from the limb. A stable fracture in a good position heals in a splint or cast. A displaced, unstable or joint fracture usually needs fixation, with plates and screws or with a nail inside the bone.

The great advantage of modern fixation is that it allows the joint to move early, before stiffness sets in.

Upper limb: proximal humerus (shoulder) fracture

This is a break at the upper end of the arm bone, close to the shoulder. It usually happens to people over 60, after a fall onto the side or the outstretched hand. The shoulder is very painful, and within days bruising appears and tracks down the arm.

Most are only slightly displaced and heal with a sling and early pendulum exercises. When the pieces have shifted a lot, plate fixation is discussed or, at an older age with poor bone quality, a reverse shoulder replacement. Dr Skotidis has presented work on this at the Hellenic orthopaedic congress. After a fracture like this, a check for osteoporosis is worth having.

Upper limb: forearm fractures

The forearm has two bones, the radius and the ulna, which work together to turn the palm. When both break in an adult, their position has to be restored accurately, or forearm rotation is lost. That is why these fractures are usually treated with surgery, with plates and screws.

An isolated ulna fracture that has not shifted can heal in a splint. With every forearm fracture the elbow and wrist are checked carefully, because a dislocation may be present too.

Upper limb: wrist (distal radius) fracture

This is the most common fracture of the upper limb, after a fall onto the outstretched hand. The wrist swells and, when the fracture has shifted, takes on a typical shape.

Fractures that have not shifted heal in a cast over about six weeks. Displaced ones need to be set and followed closely with X-rays. Unstable fractures and those that reach into the joint are fixed with a plate on the palm side, which lets the wrist move early. In people over 50 it is often the first fracture of osteoporosis. After a fracture like this, a check for osteoporosis is worth having.

Lower limb: femoral neck and intertrochanteric hip fractures

These are the two main hip fractures at an older age. A femoral neck fracture happens inside the joint and is usually treated with a partial or total hip replacement. An intertrochanteric fracture happens a little lower and is fixed with a nail inside the bone.

Both are operated on quickly, so that the patient can stand the next day. See the page on hip fractures for the details. After a fracture like this, a check for osteoporosis is worth having.

Lower limb: tibia (shin bone) fractures

The shin bone breaks mainly in two places, and each is treated differently.

• Tibial plateau (near the knee). The fracture reaches into the joint. A CT scan is needed for planning and, when the joint surface has sunk, it is lifted back and fixed with a plate. Dr Skotidis has presented work on the posterior approach to these fractures.
• Tibial shaft. Usually treated with a nail inside the bone, which allows early weight bearing.

Note: calf pain that keeps getting worse and does not ease with painkillers after a shin fracture needs an urgent examination.

Lower limb: bimalleolar ankle fracture

In a bimalleolar fracture both ankle bones are broken, the inner and the outer. The ankle loses its stability and the joint can slip out of place. That is why these fractures are almost always operated on, with a plate and screws, so that the joint goes back exactly where it belongs.

At an older age the bone is softer and the skin more fragile, so the technique and the timing of the operation are chosen with particular care. After a fracture like this, a check for osteoporosis is worth having.

Lower limb: fifth metatarsal fracture

This is a break at the outer edge of the foot, usually after the foot rolls inwards. It is often mistaken for a simple sprain.

• Avulsion fracture of the base. The most common type. It heals in a walking boot, with as much weight as pain allows, over four to six weeks.
• Jones fracture. A little further forward, in an area with a poor blood supply. It heals more slowly and needs time off the foot. In athletes, fixation with a screw is often discussed.
• Stress fracture. In runners and dancers, with pain that builds up gradually.

Pelvic fractures at an older age

After a simple fall, an older person may have groin pain and trouble walking, with a normal hip on the X-ray. Often the cause is a fracture of the pubic rami of the pelvis, sometimes together with a fracture of the sacrum. If the X-ray shows nothing and the pain persists, a CT or MRI scan is needed.

These fractures are usually stable and are not operated on. Treatment is good pain relief and getting moving as early as possible, with a walker, because staying in bed carries risks of its own. The pain settles over six to eight weeks. After a fracture like this, a check for osteoporosis is worth having.

Osteoporotic spine fractures (thoracic and lumbar)

In osteoporosis, a vertebra of the thoracic or lumbar spine can collapse with very little force: bending, lifting, even a cough. The signs are sudden pain in the upper or lower back, loss of height and, over the years, a stoop.

Most are treated without surgery, with pain relief, a short rest, early movement and, for some people, a brace. When the pain cannot be controlled, kyphoplasty is discussed, together with a spine specialist. Numbness or weakness in the legs needs urgent assessment. The most important step is treating the osteoporosis, because one spinal fracture multiplies the risk of the next.

Periprosthetic fractures

Fractures around a hip or knee implant are a category of their own, with their own treatment. See the page on periprosthetic fractures.

Healing and rehabilitation

Upper limb fractures usually heal in 6 to 8 weeks, and lower limb fractures in 3 to 4 months. Healing takes longer with smoking, diabetes, poor nutrition and older age.

Rehabilitation starts on day one, by moving the joints that are not immobilised. After the cast or the operation, physiotherapy brings back movement, strength and balance.

A fracture as the first sign of osteoporosis

A fracture of the wrist, shoulder, hip, pelvis or a vertebra, after a fall from standing height in someone over 50, is not just bad luck. It is a sign that the bone has weakened. Treating the fracture is half the job. The other half is testing for and treating osteoporosis, so that the next one does not follow.

Common questions