John D. Burrow, DO
One of the more complicated types of bone fracture to treat is the comminuted fracture. This is where the bone breaks into three or more pieces, typically caused by a high-force accident or trauma, such as a fall from a height, a motor vehicle crash, or a contact sports injury. Often the bone will break into multiple pieces at the sites of the fractures. In this article, I will discuss this fracture, how it is diagnosed and almost always treated with surgery.
The symptoms of a comminuted fracture will be severe pain that increases with movement, swelling, bruising, deformity of a limb or body part, seeing the fractured bone through the skin, inability or difficulty moving the affected body part or limb. As this type of fracture may have multiple, broken, jagged edges caused by the intense energy of the accident, often fractured bones or bone fragments can be forced through the skin, in what we call an open or compound fracture. This complicates the situation by introducing an open wound into the fracture equation, increasing the chance for contamination and subsequent infection.
Typically, a person with this type of injury is going to initially be evaluated in an ER, even if they go to their PCP or an Urgent Care first for triage and x-rays. The reason for this is that a comminuted fracture requires surgery to repair, usually with the addition of some hardware (rods, plates, screws, pins, wires) to put all those bone fragments back into their proper position and keep them in place while the bone heals. If the fracture was open, the wound must be decontaminated and all accident debris must be removed…which could be grass and dirt from a football field, grease and glass from a motor vehicle, or sand and gravel from a construction site.
It is also important to remember that individuals that are involved in high-energy accidents often may have multiple, even life-threatening injuries occurring at one time. If I am on call at the hospital, I may be working with other surgeons to appropriately time and stage the patient’s orthopaedic surgery in order of priority. Sometimes, it is even necessary to postpone the orthopaedic surgery for a day or two, even a week or so, until the patient’s condition stabilizes enough for them to safely undergo surgery.
With severe injury, many people will be hospitalized for several days and require rehabilitation. For lesser injuries, it is possible to treat with surgery as an outpatient, if appropriate. A splint will be applied after surgery, which usually stays on for two weeks or until the patient follows-up with me in the office. Once removed, we may again use a splint as we follow healing.
With a surgical incision to heal as well as the fracture, I must pay attention to provide extra soft padding and cushion over the fracture and incision during the initial stages of healing. Patients will almost always be non-weight bearing to allow for healing. As with most fractures, the acute healing process can take anywhere from six to twelve weeks, with the complete healing process taking up to a year for a complex comminuted fracture.
Immediately after surgery, we’ll use intermittent icing and elevation to reduce swelling and provide pain relief, as well as anti-inflammatory medication. Serial x-rays will be taken to monitor the healing of the multiple bone fractures. When the bone has formed a callus and healed, I will then order Physical Therapy for the patient to regain strength and range of motion in the affected body part. As with any area of the body that has been forced to stay still and be inactive for any length of time, there will be muscle atrophy and loss of strength. The Physical Therapist will be essential to the patient in moving their recovery progress along as quickly as possible with strengthening exercises and ROM stretching, as well as with inflammation reduction modalities.