Assessing injuries after a fall: Is it broken? In doubt, have it checked

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TORONTO - Sticks and stones may break your bones - and the same can often be said for taking a tumble from playground equipment, wiping out at the hockey rink or spectacular crashes on a ski slope.
For Canadian teen pop sensation Justin Bieber, it was stumbling into something on stage in London in late November that made his "ankle roll in a very bad way," according to one of his tweets, and put him in a cast.
The causes vary - everyone has a unique story - but thousands of Canadians are hospitalized each year with broken arms and legs, and countless others are treated for limb fractures in emergency departments. At this time of year, snow and ice are often involved.
"We see people slipping and falling and hurting their wrists and their ankles and dislocating their shoulders," said Dr. Stewart Wright of the Holland Orthopaedic and Arthritic Centre in Toronto.
"Certainly if there's ever an ice storm, there's a real influx of people to the emergency department. I can remember once as a resident years ago seeing about 14 patients in one day coming in with wrist fractures."
The numbers are actually quite staggering.
Statistics from the Canadian Institute for Health Information show that there were 58,722 hospitalizations in Canada (excluding Quebec) for lower limb fractures in fiscal 2008-09, and 27,992 for upper limb fractures - numbers that have risen over the past few years.
And thousands of people aren't hospitalized, but X-rayed, treated for broken bones in emergency departments and sent on their way to recuperate. In Ontario alone, CIHI statistics show there were 57,854 visits to ERs for arm and leg fractures from December to March last winter, up from 51,244 for the same four-month period two years earlier.
When someone crashes down, then attempts to get up amid howls of pain and a sinking feeling that an appendage may be damaged, there are a few checks to make in those initial few minutes.
"If it's the lower extremity ... if you can't bear weight on it, then there's a good chance you've done something bad to it," explained Wright, chair of the medical and scientific committee at the Canadian Orthopaedic Foundation.
"It may not be broken - it may be a bad ligament injury. But if you can't bear weight on it, if they get dramatic swelling, if they get a lot of pain that's causing them not to be able to weight bear, those are all things that would say you need to go in and have somebody look at this."
The foundation's latest newsletter OrthoLink contains similar advice, noting the worst injuries have open wounds and exposed bone, or fingers that are bent where they shouldn't be.
"With the upper extremity ... if there's some obvious deformity, a lot of swelling, a lot of pain, they can't move their hand, they can't ... push on a desk, sort of thing, then there's a good chance they've done something bad to it," Wright said.
As for pain, he said the covering around the bone has a lot of nerve endings that are tender when torn. Besides bones, other components to such an injury involve soft tissues - skin, subcutaneous tissues, tendons, ligaments, muscles.
"The swelling that occurs relates to bleeding from within the bone, bleeding from around the soft tissues, and the generalized inflammatory response," Wright said.
In a young person with sturdy bones, fairly simple fractures are more likely, but in an older woman with soft bones, for instance, there might be quite a few pieces.
"If the bone has shifted dramatically, then you would talk about it as being displaced. If it's basically just a little crack in the bone, which you sometimes see when people fall on their wrist, it would be undisplaced," he said.
"You might manage this with a splint as opposed to a full cast."
Surgery can be called for if fractures are unstable, or badly displaced. Otherwise, a cast - plaster or the somewhat lighter Fiberglas version - is still the mainstay of treatment.
But that's just the beginning of what can be a long road to recovery.
"When we take your wrist fracture cast off at six weeks, the bone is healed, but it's really stiff and it has to do with the soft tissues around it that have become very, very stuck down," Wright said. "It takes a long time for them to get their range of motion back, get their strength and their function back."
Pain from the soft tissue injury can last for as long as 12 to 18 months, he said.
Scott Anderson, a member of the Saskatchewan Physiotherapy Association, said people think a broken arm or leg is a six- to eight-week phenomenon because that's how long a cast is on.
"That just means the bone is strong enough to take some stress," he said. "It often is three to four months before they regain their function."
Anderson, who has been practising for more than 20 years, said he's noticed that the use of immobilization, whether it's a cast or brace, is significantly less than it used to be. Younger orthopedic surgeons tend to try to get people out of casts sooner, he observed, to mitigate the "huge negative effect."
Three or four weeks of inactivity is enough for a person to lose 50 per cent of conditioning, "so you can imagine that six weeks of inactivity would be harmful to an unhealthy person with poor cardiovascular status."
Six weeks in a cast can mean the loss of 60 or 70 per cent of the strength in the arm or leg, said Anderson, who spent 13 years as a physiotherapist with the national track and field team.
A shorter period in a cast is a positive thing, he said, but it puts more responsibility on his profession.
"It means that I will have that person at a time frame when there may be more risk. The healing is not complete."
There's also a psychological component to rehabilitation due to a fear of reinjury, he said.
"You must gain that person's confidence, you must progress them in true weight-bearing if it's lower limb, or through use, if it's an upper limb, in a way that's safe," he said.
Prescribed exercises could be different for a middle-aged person, an 85-year-old and a 12-year-old, he said.
"It's not like we say it's this fracture, so we pull out a sheet and that's the set of exercises for everybody. They'll be quite different depending on the individual."

Organizations: Holland Orthopaedic and Arthritic Centre, Canadian Institute for Health Information, CIHI Canadian Orthopaedic Foundation Saskatchewan Physiotherapy Association

Geographic location: TORONTO, London, Canada Quebec Ontario

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