How bone fractures heal

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

Today I'm talking with a pediatric orthopedic surgeon about fractures in children. Dr. Rajin Shahriar is an assistant professor at Upstate.

Welcome to "The Informed Patient," Dr. Shahriar.

Rajin Shahriar, MD: Thank you for having me.

Host Amber Smith: I'd like to begin by asking you to describe the role of an orthopedic surgeon.

Rajin Shahriar, MD: An orthopedic surgeon is a doctor that takes care of all musculoskeletal problems. They could be injuries such as broken bones or dislocated joints, or they could be more generalized problems likedeformities, congenital or developmental issues, things of that nature.

Host Amber Smith: And then someone like yourself, you specialize in children. Why are there orthopedic surgeons who specialize in pediatrics?

Rajin Shahriar, MD: There are orthopedic surgeons who specialize in pediatrics because pediatric patients pose a different set of problems than you encounter in adults. Children are growing. They're not just little adults. And they have a unique set of anatomy and problems that makes taking care of them a little bit more challenging and takes a little bit more care.

Host Amber Smith: So we'll get into a little bit more about that, but can you describe some of the injuries that may happen in a child when they hurt their arms or legs?

Rajin Shahriar, MD: So certainly the most common thing that comes to most people's minds are fractures. But it's also possible to have soft tissue injuries, and what we mean by that is everything around the bones. So that could be things like ligaments, tendons, or even cartilage or other structures that make up our arms or legs, potentially even the nerves or blood vessels, which can be damaged in more serious injuries.

Host Amber Smith: You mentioned fracture. Is that the same thing as breaking a bone or a crack?

Rajin Shahriar, MD: I think that's a very common question, and I would define a fracture as some injury to the bone that disrupts its integrity. And you can see that that's a very generalized description because that really is a very general term for describing an injury to a bone.

Host Amber Smith: Are some fractures worse than others, then?

Rajin Shahriar, MD: Because fracture is such a general term, there are many kinds of fractures. One common analogy I like to make is dropping a dinner plate or a piece of kitchenware on the ground. And what happens is that you can get many different kinds of patterns of breakage to that when that happens. Sometimes when you drop a plate on the ground, you'll have just one crack, and the plate still holds together. So you have fractures that basically don't disrupt the integrity of the bone to cause displacement. Other kinds of fractures are like plates where if you drop them it would shatter into a thousand pieces, and those are also fractures. So, you can see that there's a wide variety of what fractures can be.

Host Amber Smith: Are there other injuries that can go along with a fracture?

Rajin Shahriar, MD: Yes. Like I mentioned earlier, there's a lot of stuff around the bones that can get injured at the same time as a fracture happens. And usually there is some kind of injury to the soft tissues when a fracture happens because a bone is sort of the deepest part of the limb. So anything that's around the fracture can get damaged. And that could be muscle, could be tendons, ligaments, could be nerves, could be blood vessels such as arteries or veins. Any of that is susceptible to injury. But the good news is that many of those injuries will heal up on their own.

Host Amber Smith: So let's talk about how a fracture in a child differs from a fracture in an adult.

Rajin Shahriar, MD: Perhaps the biggest thing that makes a child's fracture different from an adult's is their ability to remodel. So what that means is that children are growing, and their bones are also growing, and bones have something called a growth plate that allows the bone to grow over time. And the power of the growth plate is its ability to correct out deformities that fractures create.

And so because a child has a growing growth plate, they can straighten out many kinds of fractures and injuries and heal better than an adult would be able to with the same kind of injury.

I think another thing that's important to know is that children have more elasticity of their musculoskeletal system, and that's clear to anyone that's been around any child that if they fall or have an injury, they bounce right back, and they almost act like they haven't sustained any injury at all sometimes.

And that's because children have, generally, a lot more flexibility than adults. And if you remember from high school physics class, whenever there's an injury, there's a lot of kinetic energy that goes into your body that gets dissipated along your tissues. So if that part of your body is very stiff, that's what creates the fracture. But if your body's able to bend and absorb that energy, then it will just bend and a fracture won't happen. So, that's another thing that makes children different from adults.

And I think the last thing is children have much more healing potential than adults because over a lifetime, adults tend to accumulate different diseases or disorders such as high blood pressure or diabetes or atherosclerosis. And these things essentially make it harder to heal, and children don't have most of those things, and so therefore their healing ability is much greater.

Host Amber Smith: Now let me ask you, on the growth plate that you mentioned, do children have these growth plates in their bones until the bones are fully formed?

Rajin Shahriar, MD: Yes. All children have growth plates on their bones until they're fully formed. And one thing that's also interesting to know is that many of these growth plates close at different times. So it's not that all of the growth plates in the body will close at the same time. Actually, some of them will close much later than others. Just to give you an example, the growth plate around the collarbone doesn't close until someone's in their 20s, but the growth plates around someone's femur or the thigh bone may close closer to mid to late adolescence.

Host Amber Smith: Are you able to tell that before you start taking care of someone? Or is there, do they show up on X-rays?

Rajin Shahriar, MD: Yeah. The growth plates show up on X-ray, and oftentimes they help us to know how quote unquote "skeletally mature" a child is. Because just because a child is a certain age doesn't mean their skeleton is also the same age. And so the appearance of the growth plates is a very helpful indication to us to assess someone's growth potential and also, the healing potential to an extent of different kinds of fractures and injuries.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Dr. Rajin Shahriar. He's an assistant professor of pediatric orthopedics, and we're talking about what to do for kids with bone fractures.

I wanted to ask you, though, are fractures involving joints necessarily more difficult to care for?

Rajin Shahriar, MD: In many ways, fractures that damage the joints are more difficult to take care of. And the reason is because fractures that go into the joint damage the cartilage of the joint. And cartilage does not heal in the same way that bone can heal. And the reason for that is because the mechanical environment and the biological environment both are different in the parts of the joint that have cartilage than the parts than the general parts of the regular bone.

Some of the things that we strive to achieve for joint fractures, as orthopedic surgeons, is that the cartilage really has to be lined up really well. And that's true for both adults and children. We don't like for there to be a large gap in the joint cartilage because that can really cause problems in the long term.

The other thing that's unique about joint fractures is that they can potentially also cause additional stiffness because we get our motion through our joint. So if there's a fracture that goes into the joint, that can predispose to greater degrees of stiffness than fractures that are outside of the joint.

Host Amber Smith: Well, let's talk about healing. What do you do to ensure that a fracture heals well?

Rajin Shahriar, MD: I think the most important things is to make sure that the fracture is lined up well. Like I mentioned earlier, children are generally able to tolerate a greater amount of malalignment than adults because of their remodeling potential. But it still needs to be lined up to a certain extent. And that means that someone who knows what that limit is needs to be involved in the care of these fractures to make sure that they are lined up well enough that they won't cause any long-term problems with regards to the functioning of the limb.

Once the fracture is lined up well, they need to be immobilized properly. Like I mentioned earlier, fractures come in different types and varieties, like the dinner plate that didn't really crack very much and didn't displace or shift that might not need a lot of immobilization at all. Some fractures don't require a lot of immobilization. Some fractures need really good immobilization, and the purpose of that immobilization is to make sure that that alignment stays where it is.

And the third goal of treating fractures is that we achieve a balance between that immobilization and the motion and function. Just to use a silly example, if we immobilized a fracture for a year, that would probably mean that you could protect that bone and make it heal really good for a year. But that would create a lot of stiffness and other problems that would be very limiting. And so the art of treating fractures is really striking a good balance between immobilizing it just long enough so that it can heal versus removing that immobilization and allowing motion so that the function can return to the arm or leg.

Host Amber Smith: Are there things that the patient or their family need to do to help the healing go smoothly?

Rajin Shahriar, MD: Yeah. The first thing is having the fracture evaluated at the appropriate time interval. So that means coming in to see the pediatric orthopedic surgeon when the fracture happens, having it evaluated and making those decisions on the alignment and immobilization, and then checking to see if the alignment is stable over time or if it loses alignment over time, then additional interventions may have to be done, and then removing the immobilization at an appropriate time. So really following up and treating the fracture as the evidence would indicate.

I would say the other things to do, from a general standpoint, is just to make sure that we create a safe environment for the kids while the fracture is healing. So for instance, the day after having a fracture and being placed into a cast probably is not the best time to go jumping on the trampoline. So just making sure that the environment that we have for our kids is safe while the fracture heals. And then lastly, having just general good health and nutrition, making sure that we're eating appropriately balanced diet and have appropriate vitamin intake.

Host Amber Smith: When might a fracture require surgery?

Rajin Shahriar, MD: That's a really good question. When the alignment is not satisfactory, that is the most common reason for needing potential surgery. Sometimes the fractures that are in poor alignment can be realigned just by manipulation, like for example, in the emergency room. But many fractures are not able to be restored to the appropriate alignment with just that method alone and may need surgery. Some fractures are very, very difficult to immobilize, so you can imagine, for example, a fracture in the hip is quite difficult to immobilize. And some surgery is needed for the purposes, even if the alignment is not terribly off, need surgery for internal immobilization or immobilization with plates and screws or other implants, to be able to provide the sufficient level of immobilization to keep that from displacing further.

And I would say rarely is it needed in pediatrics, in particular, to do surgery because there's a very strong need for early motion. There are a few examples of that I can mention if people are interested. But, that would be the most rare reason for needing surgery.

Host Amber Smith: In general, how long does a fracture take to heal in a child?

Rajin Shahriar, MD: Generally fractures have a three-part process by which they heal. And the first part of the healing process is actually the fracture itself creates bleeding and injury that the body knows to respond to. So what happens is that when the bone breaks, it bleeds, and the signals from that bleeding create an inflammatory response. And the body sends themselves and other tissue-healing properties to regenerate that area of damaged bone. And that process starts immediately after the fracture happens and continues for several weeks.

Then, there's a process by which the body will try to unite or bring those two pieces of bone back together. Oftentimes, the way that the body will do that is by actually forming cartilage first. And that cartilage basically increases the stiffness at the fracture site, and that callous eventually turns into bone through the body's healing process. But interestingly, you can't see a lot of that callous on the X-ray. So many times when we see families in clinic, we have to tell them about the way the fractures healed because oftentimes they're looking for the signs of healing very early on when it is probably healing, but we can't see it on X-ray.

So once the bone has joined back up together, we call that "union," basically the fracture having joined back together. But there's a third phase called remodeling, and that takes many months to years. The way that I like to talk about remodeling is comparing it to when you get a big cut on your skin. So the first thing that happens is that, just like with bone, it bleeds, but then it heals together, and it makes a scab. So that scab is what we call callous, or union for bone. And then remodeling is when that scab falls off, and then the skin is usually a little bit hyperpigmented or dark. And then it takes months for that color to fade away and go back to normal.

So that's what remodeling is in bone as well, where the bone will change shape, straighten out, do other things in order to go back to its final form. And that takes many months to years.

Host Amber Smith: What would you advise parents to do if their child injures their arm or leg?

Rajin Shahriar, MD: I think the most important thing to do is to assess your child. As the parent, we often have a really good idea of our children, how they behave normally. How does my child typically respond to injuries? Are they getting better? Is there a visible deformity that I can see on the arm or leg? Is there significant swelling that just developed? Is it getting worse? Are there things going on with the color? Like, is the arm or leg turning white? so those would be signs that something more major is going on.

And sometimes, there's a dramatic injury, and within a few hours, the child is almost back to normal. And so that's a positive sign. But sometimes these injuries are not getting better within a reasonable timeframe. And really at that point in time, there should be an attempt to get additional evaluation.

But while that assessment is happening, right after the injury, the next few hours or days, some supportive care that may be helpful is first of all, immobilization. So no matter what the injury is, whether it's a fracture or a strain or a sprain, there is going to be some injury to the tissues that causes pain when those tissues are stretched or moved. So immobilization will allow those tissues to rest right after the injury and start to feel better. And so that can be done. If it's an acute injury, they may need a makeshift splint that you make from whatever materials you have available. If it's over a longer period of time, they sell little splints and things that you can get at your local pharmacy or a grocery store or department store. And all those options are good for immobilization. Amazon or Walmart also has options that can be obtained online.

Icing is very helpful to decrease inflammation as well. And pain medications that are available over the counter, such as Tylenol or Motrin, can also help with the pain.

Host Amber Smith: Well, Dr. Shahriar, thank you so much for making time for this interview.

Rajin Shahriar, MD: You're welcome. Thank you for having me.

Host Amber Smith: My guest has been pediatric orthopedic surgeon, Dr. Rajin Shahriar. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.