Broken Bones and Fractures

DEFINITION

In any circumstance in which a significant accident precedes the onset of back or neck pain, a broken bone (fracture) must be suspected. In young and healthy patients, the amount of force required to fracture the spine through the bone or soft tissue is quite high. Therefore, an accident with a great deal of trauma is required: a motor vehicle accident, a fall from a height landing on the back or feet, a sports related injury, and other circumstances in which a large amount of force travels through the spine. Less force is required to fracture the spine of patients who are very young (less than eight), very old, or have other medical problems that decrease the strength of bone (such as patients on long term steroids). In younger patients, a lot of the bone is still cartilage and, therefore, not as strong as an adult’s spine. In older patients, the bones have weakened from the naturally occurring phenomenon of bone loss as we age. Also, osteoporosis is more common as we age.

WHO GETS A FRACTURE AND WHY

In a situation such as a motor vehicle accident or fall from a large height, the patient will usually have been seen in the emergency room and diagnosed with the fracture. However, three scenarios exist in which a fracture may be picked up late.

In the first scenario, the individual may feel well and not go to the emergency room or see a doctor. The pain in the back or neck may come on and increase over time. Usually, the patient will note a decreasing ability to perform routine activities. Any weakness or numbness in the legs or arms should be investigated immediately.

A second scenario is the patient who is seen in the emergency room, but did not complain of pain in the back. This patient may have had other more painful injuries, thereby keeping the patient’s focus on that area (such as a broken leg). The pain is so severe in another region, that the patient does not realize he or she has pain in the back or neck and that area does not receive the attention of a physician. Alternatively, the patient may be feeling a euphoria or adrenaline rush from the excitement of the injury and surrounding circumstances that may temporarily mask a broken bone. This situation can be seen when another individual has been hurt and the patient’s focus is on that person, instead of himself.

A final scenario is one in which the patient is seen by a physician, x-rays are taken, and no fracture is seen. Pain continues and there is no improvement in the condition of the patient. Some fractures in the spine are subtle and can be difficult to detect on plain x-rays. Some injury patterns are breaks only through the soft tissue that cannot be seen on x-rays. In these situations, follow-up x-rays or further studies such as an MRI, CT scan, or bone scan can help to define the injury.

TREATMENT

The treatment of spine fractures is dependent on the type of injury, the neurological status of the patient, the general health of the patient, and the amount of time that has passed since the injury. The most important aspect of treatment is diagnosis. Early diagnosis will improve the outcome through prompt and appropriate treatment. It would be impossible to diagnosis a specific type of fracture through this venue or discuss the different types of fractures and their treatments here. Not enough space exists here to discuss types and treatments of spine fractures, as whole textbooks have been written on spine trauma (i.e. Wheeless Ortho Textbook). More importantly, a detailed discussion by your physician relating to the specific type of trauma, the treatment, and the expected outcome is the best source of information.

COMMON SYMPTOMS OF HERNIATED DISCS

A patient with a herniated or “slipped” disc can have leg and/or back pain. The most common presenting complaint is that of shooting pain down one or, although uncommon, both legs. The pain will typically travel from the back or buttocks to below the knee, following the path of a specific nerve root. The following are drawings of typical nerve root distributions. The pain does not always fit neatly into one of these patterns, but it is helpful in determining which disc is herniated.

The second symptom that sometimes accompanies a disc herniation is back pain. Patients often report a history of back pain that occurred prior to the actual herniation. Many patients recall an episode of their back “going out” or of significant pain that resolved over a period of days with rest and was usually not accompanied by leg pain. Episodes of back pain that meet this description were probably caused by a disc that was merely bulging, without actually herniating. A bulging disc is akin to a tire with too much air: the air is still within the confines of the tire. When a disc herniates, the “tire” pops and lets the air out. Prior to complete disc rupture with herniation, it is characteristic for a person to experience recurring bouts of New Jersey back pain with referred leg pain. A referred pain is one that stems from another structure, in this case the disc, but is felt a short distance away. The referred leg pain is usually in the front of the thighs or in the buttocks, but not below the knees.

Additionally, a patient may experience numbness or weakness with a herniated disc. The numbness is most frequently reported to be in the calf, the sole of the foot or the big toe. The weakness is often experienced by the patient as an inability to walk up the stairs normally or to walk on the toes.  The weakness might present as an inability to lift the foot while walking (a “foot-drop”), or weakness in flexing or extending the knee, foot, or leg.

An individual who experiences a new onset of trouble controlling urine (bladder incontinence), difficulty controlling bowel movements (bowel incontinence), or numbness in the perineal region (saddle region), usually noticed after wiping in the bathroom, should contact a physician immediately as these may be signs of cauda equina syndrome which is a surgical emergency. In cauda equina syndrome, the disc herniation is extremely large and presses on the nerve roots effecting bowel and bladder control. The best chance to regain these functions is through prompt surgical decompression of the affected area. Thankfully, cauda equina syndrome is rare.

Regardless of the specific symptoms, a disc herniation can only be definitively diagnosed by trained medical personnel.

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