What is a Fracture?
 

A fracture is a crack or break in a bone. Fractures can occur from an injury, repetitive stress, or weakening of the bone. Some fractures are obvious, while others can be difficult to distinguish from a sprain, strain, or other injury without imaging. Surgery may be suggested when a fracture is significantly displaced or unstable, cannot remain properly aligned without fixation, involves certain joint surfaces, is open, or causes significant injury to surrounding structures.

Signs & Symptoms of a Possible Fracture
 

• Pain after an injury

• Swelling or bruising

• Tenderness directly over a bone

• Pain with movement

• Difficulty using the injured area

• Difficulty bearing weight

• Deformity

How Are Fractures Diagnosed?

 

-X-Ray - X-rays are usually the first imaging test when a fracture is suspected. However, small or nondisplaced fractures can occasionally be difficult to see.

If a fracture is still strongly suspected despite normal X-rays, the area may be protected while additional evaluation is performed. Depending on the suspected injury, this may include repeat X-rays, MRI, or CT. 
 

When Is an X-Ray Needed?

Ottawa Ankle and Foot Rules
 

After an acute ankle or foot injury, an ankle X-ray is generally indicated when there is pain around the ankle and at least one of the following:
 

• Tenderness over the back edge or tip of the lateral malleolus (outer ankle bone)

• Tenderness over the back edge or tip of the medial malleolus (inner ankle bone)

• Inability to take 4 steps both immediately after the injury and during the medical evaluation
   

A foot X-ray is generally indicated when there is pain in the midfoot and at least one of the following:
 

• Tenderness at the base of the 5th metatarsal

• Tenderness over the navicular bone

• Inability to take 4 steps both immediately after the injury and during the medical evaluation

Ottawa Knee Rule
 

After an acute knee injury, a knee X-ray is generally indicated when at least one of the following is present:
 

• Age 55 or older

• Tenderness isolated to the kneecap

• Tenderness over the head of the fibula

• Inability to bend the knee to 90°

• Inability to take 4 steps both immediately after the injury and during the medical evaluation

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Stress Fractures
 

A stress fracture is a true fracture caused by repetitive loading of a bone rather than one major traumatic event. Bone stress injuries occur along a spectrum:

Bone stress reaction → Stress fracture → Complete fracture → Possible displacement

Continuing to repeatedly load an injured bone can allow a stress injury to progress.

When Should a Stress Fracture Be Suspected?
 

Consider a stress fracture when there is gradually developing, localized bone pain without a major injury, particularly after repetitive activity. However, stress fractures can occur without excessive activity, especially when the underlying bone is weakened.

Risk factors include:
 

• Increasing training too quickly

• Excessive repetitive exercise

• Inadequate rest and recovery

• Inadequate calorie intake relative to exercise demands

• Relative Energy Deficiency in Sport

• Low calcium intake

• Vitamin D deficiency

• Osteoporosis or low bone density

• Menstrual or other hormonal abnormalities

• Eating disorders

• Malabsorption disorders such as celiac disease

• Certain metabolic or endocrine disorders

• Chronic corticosteroid use

• Smoking or nicotine exposure

• Biomechanical or footwear problems

Symptoms include:
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• Sudden increase in training distance, frequency, or intensity

• Localized tenderness directly over a bone

• Pain with weight-bearing or repetitive loading

• Pain that improves with rest and returns with activity

• Pain that progresses from exercise-only pain to pain with walking

• Persistent focal bone pain despite a normal initial X-ray
   

Treatment of Stress Fractures
 

The injured bone needs time to recover from repetitive loading.

Treatment for low-risk stress fractures may include:
 

• Temporarily stopping the activity responsible for the injury

• Avoiding painful running, jumping, or impact exercise

• Walking boot when appropriate

• Crutches or restricted weight-bearing when needed

• Maintaining fitness through pain-free lower-impact activities when appropriate

• Gradual return to activity after healing

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High-Risk Stress Fractures
 

High-risk stress fracture occur in a location and/or configuration that has a higher chance of progressing, displacing, healing poorly, or causing serious complications.
 

Some high-risk stress fractures include:
 

• Femoral neck / hip

• Anterior tibia / shin

• Navicular bone of the foot

• Proximal fifth metatarsal / pinky toe

These injuries generally require prompt activity restriction and orthopedic evaluation, requiring:
 

• Strict limitation of weight-bearing

• Crutches

• Immobilization

• Close imaging follow-up

• Surgical fixation in selected cases

How Long Do Fractures Take to Heal?
 

Healing time varies according to the bone, fracture severity, age, health, and other factors. Many uncomplicated fractures require approximately 6–8 weeks for substantial healing, although some heal faster and others take several months. Pain improving does not necessarily mean the bone has regained its full strength. Return to strenuous exercise or sports should occur gradually after adequate healing and restoration of function.

When Is a Fracture an Emergency?
 

• Bone visible through the skin

• An open wound over a suspected fracture

• Severe deformity

• Uncontrolled bleeding

• A pale, blue, or unusually cold extremity

• New numbness or significant weakness

• Severe or rapidly increasing pain or swelling of an extremity

• Suspected neck or spinal fracture

• Major trauma

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                                                       References & Guidelines
 

• American Academy of Orthopaedic Surgeons (AAOS)

• American College of Radiology (ACR) Appropriateness Criteria

• American Medical Society for Sports Medicine (AMSSM)

• Current sports-medicine guidance regarding bone stress injuries and Relative Energy Deficiency in Sport (RED-S)

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