Caitlin Whyte (Host): A fracture or a broken bone can happen in more ways than one. So today we are joined by Dr. Anthony Villare, an Orthopedic Surgeon at Upland Hills Health in Dodgeville to discuss fractures, surgery and recovery from them. This is the Inspire Health Podcast from Upland Hills Health. I'm Caitlin Whyte. So Doctor, I'd love for you to start out with a pretty broad question here. Tell us what are the different kinds of fractures and what are some common causes for each one?

Anthony Villare, DO: Fractures can just cover a broad range of injuries. I mean, that's how most people get these, they trip, they fall. I think the ones that would most come up in people's minds would be wrists or ankle fractures. You know, we all fall, we all twist our ankles and stuff, but, if you want to get down into the weeds of fractures, technically you could break any bone in your body, you know, and that's a fracture.

A break is a fracture. And that's something that some people don't understand either. But they're the same thing. Now, you can have what commonly people call a compound fracture. In orthopedics, it's an open fracture. That's where the bone actually comes out through the skin. That is an emergency. You can't just sort of set that and go home with it. You need to have surgery for that. That is an orthopedic emergency. Wrist fractures usually occur by the joint. You can have a fracture that's in the joint or one that's outside the joint. But even with those fractures, what we as orthopedics are concerned about, is how those bones line up. And we always try to think the best way for this bone to heal, regardless of what kind of fracture it is, is if it heals in the most anatomic or normal position possible, bone heals with bone and that's fine. But once you break. Once the fracture line goes into the joint, you know, you may have some scar tissue that forms there. And if it breaks bad enough in the joint, or involving the joint, then people can have what we call post-traumatic arthritis at the joint down the road. It doesn't happen immediately.

It could happen years later, you know? But whenever we see a fracture, as a surgeon, I'm thinking either surgery, or no surgery? Can I treat it with a ca with a cast or do I have to take you to the operating room? Does it need extra support with plates and screws or something like that, you know, to hold it until it heals, the body will heal it.

We just want to make sure that it heals it in the best possible position, cause that that's where it starts. That's going to allow,  or stack the odds for the patient for them to get back to normal function, normal usage, normal mechanics of that joint or that limb. It all starts with the bone looking straight or in good alignment or as we said, you know, anatomic. Sometimes we can't do it. Sometimes it's just too, the trauma is too bad. But I mean like car accidents or something. But that's, I can't say that's everybody. Most of us have the everyday slip and fall. You know, we break a wrist. Elderly patients, you know, with osteoporosis, there's, when you start to see hip fractures and, and or, or skiers, you may have a fracture in your knee. We call tibial plateau fractures, you know, so with different sports and different activities, you're going to have different injuries.  But it all starts with it all, you know, for us, it all starts with trying to get it to look as anatomic as possible. How can we do that? Just a cast or surgery. We don't want to have any kind of gap where the bones are.

We don't want to have any gaps in the joint. We try to get it back as best we can. The body does have a wonderful capacity to heal and remodel, so every fracture does not have to be anatomic. There are degrees that we can accept. There are, you know, latitudes that we can give, and then the body takes care of the rest.

If we get it in the ballpark, reasonably good alignment, reasonably reduced and we can hold it there, then you know, the body takes care of the rest. The first two weeks are usually the most important. That's when we have a chance to set the bone and set that fracture back to where we want it and hold it there.

 After about two weeks, there's enough healing, bone deposited around the break that it becomes much harder to move and set where we want it to be. So we have about a two week window generally to treat a fracture. We'd like to get to them earlier cause it just makes it easier to set the bone, more comfortable for the patient as well.

Host: So how does the body heal from a fracture then?

Anthony Villare, DO: That's the nice thing about orthopedics is, you know, the body usually heals any injury with scar tissue. You get a cut, you get a scar. The bone is tissue, even though it's hard tissue, but the bone is one of the few tissues in the body that heals with itself. It doesn't heal with scar tissue. So when a bone heals, it will in the end be 100% strong again. And the body is constantly, let's say moving cells around and reorganizing and remodeling that break. And it takes months and months, for it to do this to where you may not see the break at all on an x-ray. It's just gone.

The body has remodeled that bone, to a normal bone again.  Sometimes the trauma is so bad, so severe that it can't do that. And it does heal with some scar tissue. And one thing to remember also, you know, we talk about this like, yeah, you break a bone, it heals, but we know that technically there's no guarantee when a bone breaks, it will heal.

We try to get it to heal by setting it and immobilizing it with a cast or doing surgery, to stack the odds that it will heal. Some bones are harder to heal than others. You might fracture a bone in your hand like a scaphoid. It may not heal, cause it has a bad blood supply. Nothing heals if it has no blood supply.

 Types of fractures, like in your lower leg, your shin bone, your tibia, they might be hard to heal because it's very dense bone. It's harder for it to heal. Doesn't mean it won't, but some bones we always think of, like we have to give sort of extra attention to, or seriousness to others like, like a wrist fracture, it's almost going to heal. I mean, I, I, it would be very unusual for a wrist fracture not to heal. Some bones are easier to heal than others, but in the end, like I said, bones generally heal. They heal with bone tissue, and they become 100 hundred percent strong again. So, like if I were to do surgery on you, you broke your arm.

I, I'd put plates and screws on it. Once the bone is healed, you know, which could be like, let's say three months or more, you know, I'm talking like healed, healed to the point where we don't have to worry about it anymore, maybe three months. People are in casts for about six weeks. Why? Because that first six weeks after casting, after surgery, that's when the bone is the weakest and it may move out of position. So we want to be real careful that we keep it in that position. Once it's had enough healing, then it's just kind of off to the races. It just keeps remodeling and healing and remodeling and healing.

But once it's totally healed, those plates and screws really don't serve any purpose. The bone is a hundred percent. Again, we don't take hardware out of adults usually. We might in kids, we try not to leave hardware in kids. But once you're an adult, there's no plan to go back and take hardware out, in almost every case, the hardware just stays in there. It's inert, doesn't do anything. It might set off a machine when you go through the airport, but it's not really doing anything vital once the bone is healed.

Host: Well on this topic of hardware and surgery what types of fractures require surgery?

Anthony Villare, DO: Well, generally the more, the more traumatized the bone is, as we call them comminuted fractures,  generally they tend to be the more unstable ones. The more unstable ones are the ones we can't adequately set or hold in place with just a cast. And sometimes fractures that go into the joint.

 But again, not all fractures need surgery and not all  fractures that go into the joint need surgery. Not all comminuted fractures need surgery. So, so you have to look at each one, you have to see where it is in the body, and then, you know, we understand which ones tend to be more unstable, which ones tend to collapse. It might look good the first time I see you for a break. That x-ray might look good, might look decent, but I, I know just because, you know, this is what we go to school for and we train for. I know that over time that x-ray is not going to stay looking that good. It'll probably collapse and then it'll collapse so much that, you know what, though? We won't like where it is, and by the time we find that out or see that x-ray, it might be too late to do any surgery on it. It's already starting to heal in that position. So, I'll talk with patients a lot of times, I'll basically give them the odds.

I'll just say, you know, we can cast this. I can keep it in a reasonably good position, but I can't guarantee it'll stay there. It might collapse, and that might affect the function and the motion of that joint. And it might affect how stiff, how painful it might be. But then I say, but if I do surgery on it, I can internally hold it up, with the plates and screws or something, you know, I can hold it on the inside.

And that gives us more rigid fixation, better fixation to hold it up. We don't have to rely on a cast.  You know, which is prone to getting loose,  getting wet, you know, uncomfortable. There's a lot of things that go along with having a cast on. But if we can hold it on the inside, you know, hugging the bone, then it'll heal right. And, the patient has a better chance of getting back. That, especially I, discussed this, especially with wrist fractures. Our plate and screw technology has advanced over the decades. In the old days, we would put this erector set on the outside of the wrist and hold it together.

 But that's all we had. Plates and screws failed. We didn't have good plates and screws to hold everything together. Now we can put plates and screws up there and they do a wonderful job of holding up the fracture, and keeping it like anatomic, let's say. I'll tell a patient, you can be in a cast for six to eight weeks, then come out of it, your wrist will be stiff, and then you got to do rehab.

And it may not heal perfectly. Or I can take you to surgery. There's always risks with surgery, but I can take you to surgery. I can put plates and screws on it. I can, I know I can hold it where I want it. And the nice thing about that is after I do that surgery, they don't need a cast. So you either do six or eight weeks of a cast, or if a fracture is really bad and really should be better treated with surgery, I can fix it with surgery and they're in a Velcro splint that they can take off in a couple days and start moving their wrist. Not using it, but they can move it. There's, a difference, but it's nice.

And if you've ever been in a cast, I never quite understood this until a patient, until I had it done to me. But a patient told me how they didn't like a cast because it made them feel claustrophobic. And I didn't quite understand that until I had a broken ankle. And they put me in a cast and it drove me nuts that I couldn't like get to my ankle.

I couldn't scratch where it itches. I couldn't kind of like just wiggle it a little bit or whatever, you know, and it just drove me bats until I got into a fracture boot and then I could control it and, and all that sort of of, phobia just kind of went away, you know, because now you have some sense of control of this fracture. You know, not to get off on this, but we don't put patients in a lot of fiberglass casts anymore. Even for the wrist, you know, mostly for the wrist, wrist or hand. A lot of what we do now we use EXOS casts, hard plastic casts, two shells held together with a Kevlar lacing.

And you can tighten it and loosen it, however, is comfortable to you. We soften the plastic and a little heating device in the office, and when it gets soft enough, we mold it to your wrist or your hand, and then it hardens there, and you wear that for six weeks. Now, I, I can do that for most fractures, but if it's really unstable, I'm not trust that cast to hold the fracture where I want it. And I also don't want to put that in the hands of the patient because they might loosen it. And you know, kids, you can't trust kids. They know everything, they might take the cast off. There's dangers with those kind of casts, but, we can always try treating something with some fracture injury with a cast.

But if it gets, if I know if it's really bad and really unstable, I'm going to recommend surgery. A lot of hip fractures need surgery. You can't treat those with just bedrest or whatever, it's not healthy for anybody to just be laying in bed for weeks and weeks until something heals. Femur fractures, tibia fractures, humerus fractures, you know, those type of what we call long bone injuries; in adults, they're better treated with intramedullary rods. These are titanium rods that we place down the center of the bones and that holds alignment, holds position, holds everything. And sometimes it does such a good job, people are going to start walking on these things the next day, Orthopedic technology's really,  really amazing compared to where it started when I was doing this 30 years ago, you know. So, it's really cool how things have advanced.

Host: So if surgery is then required, and like you said, sometimes it's the preferred method for a type of fracture, what does the surgeon do to repair the fracture or related injuries?

Anthony Villare, DO: Well, I, if we're talking broken bones, what we usually do, we have the, the orthopedic technology of plates and screws, or if it is a long bone injury, meaning like your thigh bone, your shin bone, upper arm bone, then we can use an intramedullary rod, which is a titanium rod, which we place down the center of the bone. And that helps rotation, it helps length, it helps alignment, helps keep everything in place.  Otherwise, plates and screws, it's always an option. And some of these things, it's up to this surgeon preference. Some surgeons are better with an incision and plates and screws to hold it all together.

Some surgeons prefer the rod down the center of the bone and they're better skilled surgically at placing those and getting alignment. So there's always options, but those are the type of surgical,  tools we use to try to get a bone stabilized, reduced, you know, to where it heals properly.

Caitlin Whyte (Host): Absolutely. So off of surgery, let's focus now on the kinds of fractures that don't require treatment. What falls into that category?

Anthony Villare, DO: Well, I think those are the low energy injuries. And remember all these injuries we cater to the patient. You know, a child with an injury versus an adult with the same injury, versus maybe like an elderly person with an injury. That same injury. You know, you always want to cater it to that individual and what their activity level is going to be. What are we hoping they get back to? A child, obviously you're going to be more particular with because they have the rest of their life to kind of use that arm or that leg. You want to make sure you get it right.

But low energy injuries tend to be more stable. Tend not to need surgery. Doesn't mean they don't need attention, you know, they might need a cast or something, but generally they tend to only need sort of conservative treatment, not surgical. And like I said, the less complicated injuries, also, the ones that the fracture isn't in multiple pieces. And that kind of goes in hand, usually the more high energy injuries, there's going to be more injury done to the bone, more fragments of bone. So it's going to be more unstable, more likely to need surgery. Whereas the low energy, the little slip and fall may not need it.

But then again, you know, I've seen some really bad wrist fractures from just people that slip in the driveway. And they just take a hard fall. The momentum just takes them down hard and yeah, that break is all the way off. And even setting the bone may not be enough, you know? So, there is as many types of breaks as there are bones in the body, and each one is handled differently because each one has a specific task, in the body.

Your shin bone versus, you know, your forearm bones. We handle those each differently. Like if you had a simple break of your forearm, you would need surgery, in an adult, because I know that bone is not going to hold up there and I know you still want to be able to turn and twist and use your hand and everything. And it may not do that because even if that initial x-ray looks good, the future x-rays may not. So there's certain areas of your body, if you break those bones, regardless of how minimal it may look on an x-ray; we know those don't hold up well with just casts. So you might need surgery. And then others, fractures in the hand, even your upper arm, some of those fractures, maybe we don't need to do surgery right away. Let's just arm sling. Let's cast it. Let's see how you do, let's keep an eye on it with an x-ray. And then we can kind of decide, if it's not holding up, then we do surgery or if it looks, keeps looking good on future x-rays, then you don't need surgery. We'll just continue on that direction of treatment, you know?

Host: Mm-hmm. No. Absolutely. And that makes so much sense. I'm gathering that there's just a lot of variables that play into fractures, where they happen, how old the patient is, you know, how severe it is. But wrapping up here, I'd like to talk about physical therapy. Is that required to say complete a recovery? Is it always needed, or where does physical therapy factor into fractures?

Anthony Villare, DO: I think physical therapy is almost always needed after an injury because it doesn't necessarily address the broken bone, but our body, it's not just the bone that's isolated. It is surrounded with all this soft tissue, muscle, tendons, ligaments, joint capsule. So those tissues are going to get injured as well, when that bone is broken. All that is going to heal with scar tissue. If we have to immobilize a joint, those ligaments and that joint capsule, it's all going to get stiff. Those tendons are not going to glide as easy if I have to immobilize your hand for a fracture. So, there's always a factor of stiffness and weakness. If you're not using that arm, that leg like you would normally, the muscles are going to get weaker.

So when you come out of a cast, you're not just going to jump and run out of the office back to the parking lot like normal. Your joint's going to get stiff. Your leg will feel weak. Your arm will feel weak. So, it would not serve the patient well if we just kind of told them, oh, don't worry about it. Just work it out. You almost have to give it a certain degree of attention after as the next phase, like after you immobilize and rest. There's always rehab after that, so that's the follow through.

There's always that rebuilding phase after an injury to help get you back as quickly as possible, back to where you were before you injured it. And that's where therapy comes in. I love therapy. It is so important to try to get someone muscle strength, joint motion, core strengthening, get it all back as best we can. We're not always successful. Sometimes the injuries are just too significant but we have to try and if we don't try, the person will never get back to where they were before they got injured. So, it's all about returning a patient to as high a functioning level after the injury as they were before the injury.

Host: Well, thank you so much for sharing your time and information with us Doctor. Check out our website at uplandhillshealth.org for more information and resources. This has been the Inspire Health Podcast from Upland Hills Health. I'm Caitlin Whyte. Be well.