It is not infrequent that trauma associated with accidents results in injury and damage to the bone structure of a person's body. Evaluation of an injury claim involving fractures requires an understanding of the skeletal system, which forms the basic structure, or framework, of the body.
Bones are made up of living cells, and, although they seem hard, they actually consist of porous materials. Bones are most dense and least porous at the cortical shell. This is the hard shell we commonly associate with bone structure. Trabecular bone, sometimes referred to as marrow, is more porous and is found within the cortical shell. It can be up to 90 percent porous and is contained in the long bones, the pelvis bones, ribs, and back vertebrae. The trabecular structure contains blood and fat cells and is sometimes described as honeycomb in appearance. There are further divisions of bone structure at the cellular level; however, knowing these two structures will suffice for most claims professionals in evaluating fractures.
Nerve endings are contained in the periosteum, which is a thin outer coating on the outside of the cortical shell. When a bone is struck, the nerves in the periosteum relay the sensation of pain to the brain. The more severe the impact or damage to the periosteum, the more significant the pain is. When bone fragments rub against each other, a grating sound is often heard or friction felt. The sound is referred to as crepitus and results in severe pain.
Children are born with 270 bones. Fusion occurs with aging, leaving adults with approximately 206 bones. Any of these bones can be damaged by trauma caused by accidents. The extent of damage may vary depending on
the age of the person, since bone tissue hardens and fuses with age;
location of the bone because of its use in the skeletal structure;
the area of the bone that is fractured or damaged;
the density of the bone as bones tend to lose density with advanced age, drug use, or other causes (such as smoking); and
the severity of the impact.
Assess the Extent of the Injury
The simplest description of a fracture is the breakage of a bone. Fractures are relatively common. According to WebMD, the average person has two fractures in his or her lifetime. There are four major categories of bone fractures:
Non-displaced, in which the bone tissue breaks but remains in proper position and alignment
Displaced, in which the bone at the point of the fracture moves out of alignment. Displacement may be contained within the tissue or may pierce the skin tissue.
An open fracture occurs when the ends of the broken bone pierce through the skin. Open fractures may result in deep bone infections as bacteria is able to enter the site of the wound and cause complications or delays in the healing process.
A closed fracture does not pierce the skin or outer tissue at the site of the break.
A closed, non-displaced fracture is generally quicker to heal than a displaced, open fracture due to complications that can arise in the latter combination.
There are various types of fractures. Each type has different implications for healing and permanency of related disability. The most common types a claims professional will encounter include:
Comminuted fractures occur when the bone fragments into a number of pieces.
Compound fractures involve extension of one or both bone fragments piercing the skin or damaging internal organs (such as a fractured rib piercing a lung).
Compression fractures occur when bone tissue is driven together. This type of fracture often occurs with falls in which individuals use their arms to break the fall, resulting in compression of the wrist or elbow bones.
Depressed fractures are frequently seen in skull injuries, in which the bone is pushed into a concave position, often resulting in brain contusions, concussions, or trauma.
Fissure fractures are commonly referred to as hairline fractures. The bone is cracked but not completely broken through—also called an incomplete fracture.
Greenstick fractures are aptly named since the bone is not broken but, rather, bent and is still in one piece. This type of fracture is often seen in children whose bones are not yet hardened.
Pathological fractures are caused by disease, weakness in bone tissue, or some other non-traumatic reason. These types of fractures may occur without any unusual force, such as the deterioration and collapse of bone tissue due to osteoporosis. When pathological conditions exist, trauma to the bone may lead to more damage than might have been expected if the secondary condition did not exist. Pathological conditions may also slow or delay the healing process.
Fractures can also be described by their appearance or shape in the bone itself.
A longitudinal fracture is lengthwise through the bone.
An oblique fracture is angled lengthwise through the bone in an oblique position.
A transverse fracture directly crosses the bone or is at right angles to the length of the bone.
A spiral fracture occurs most often when the bone is twisted and the break is a spiral shape.
Treatment of fractures usually begins with reduction—the method of realigning or stabilizing the bone in its correct position for healing. Closed reduction involves placement without surgery by manipulating the bone into proper position. Open reduction is a surgical procedure that exposes the bone ends or fragments for proper placement. Open reduction often involves the use of screws, wires, plates, or other medical devices to immobilize the bone. These may or may not be removed following the healing process, depending on the severity and placement of the break and the amount of stability required. Open reduction is more expensive due to costs related to the surgical procedure.
Complications increase as the severity of the fracture increases. If the bone is aligned well, if there is immobility during the healing period, and if there is good blood supply through the healing period to encourage proper regeneration of bone material, the fracture should heal with little or no deformity or disability. However, claims professionals should treat fractures as complex injuries, even in their simplest state, due to the number of complications that can occur. Even in the healthiest person, the bone union may involve deformity, poor blood supply may result in non-union at the site, or a pathological condition may present itself and impair healing.
Any fracture involving a wound, such as a compound fracture, poses opportunities for bacterial infection or damage to arteries that can result in necrosis or gangrene. These can escalate if not treated promptly, leading to amputation or additional surgical interventions. Fractures can also damage nearby blood veins, resulting in the formation of blood clots that may hinder blood flow or even cause death if the clot enters the heart.
Because of the potential for increased severity, claims professionals need to obtain specific information to properly evaluate the injury and potential for disability. Information that should be obtained includes:
Location of the fracture
Bones or joints involved
Damage to underlying tissue—brain, lungs, kidneys, etc.
Type of fracture
Category and description
Reduction method required
Use of pins, plates, and screws for reduction and whether removal of prosthesis will be required
Potential for disability or non-union
Loss of motion
Comorbidities, such as diabetes
Congenital conditions such as arthritis
Potential for infection
History of infection
Activity level of the injured person
Claims professionals face additional challenges when evaluating fractures, so special care will need to be taken to understand the extent of the injury, the health condition of the injured party, and the potential for permanent disability. Great care should be taken to discover as much information as possible so that later exaggeration or claim padding can be prevented.
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