Living with fractures
As explained in the section called Consequences of Osteoporosis, pain and other problems associated with osteoporosis are caused by fractures and these experiences can vary from person to person.
Osteoporosis does not affect the healing process. So, if you have a fracture, it will usually heal in about six to twelve weeks although, like any broken bone, sometimes it can take longer. If you are having problems coping at home after your fracture, there are services such as physiotherapy and occupational therapy that can help you to regain your independence.
As with any broken bone, it is really important that you are eating healthily to help with your recovery and the healing process (see here for more information about a well-balanced diet). It is especially important that you have enough protein to help the healing process, particularly if you are older and frailer.
If you smoke, a fracture may take significantly longer to heal as smoking alters the blood supply to the bones. Ask your doctor or practice nurse for help with giving up smoking to give your bones the best chance of healing well.
Some broken bones require an operation to aid healing; others get better on their own. Sometimes, a fracture needs to be immobilised (kept still) for a period of time but, with other fractures, this isn’t necessary. Here are three common fractures that can be caused by osteoporosis, how they are treated and how healing is promoted.
My doctor has told me that my bones are “soft” because I have very low levels of vitamin D. Is this osteoporosis?
It is likely that this isn’t osteoporosis, and might instead be another condition called osteomalacia. Bone is living tissue that continually renews itself by a process called bone turnover. The new bone that is made is initially a soft substance called collagen, which then needs to be coated in minerals such as calcium (through mineralisation) to make it hard and strong. Adequate levels of vitamin D are essential to enable good bone mineralisation with calcium, and so people who lack vitamin D may develop osteomalacia.
Most of our vitamin D comes from exposure to sunlight. Only a small proportion (around 10 per cent) comes from foods, such as oily fish, eggs, margarine and some cereals and fortified foods. Older people, those who do not go out much and people who cover up for religious or cultural reasons may become deficient in vitamin D. Ten minutes of sun exposure on your face and arms (without sunscreen) once or twice a day during May to September, taking care not to burn, is thought to provide enough vitamin D for most people.
Unlike osteoporosis, where fractures (broken bones) may occur due to reduced bone strength, osteomalacia (‘rickets’ in children) actually makes bones soft, and these bones can bend and crack. Osteomalacia is also very different to osteoporosis in that it can cause generalised bone pain (even when there is no fracture), stiffness and muscle weakness. For some people the pain and stiffness may be severe enough to make moving about very difficult.
As the symptoms caused by osteomalacia can vary it may not be diagnosed for some time, perhaps even years. It is often the continued pain that alerts a doctor to the possibility of osteomalacia as a diagnosis, and then a simple blood test can be done to diagnose the disease. It would be sensible to return to your doctor to discuss your symptoms and the possibility that this could be osteomalacia. Happily though, treatment for osteomalacia is likely to cure the condition, although it may take some time for the pain to ease completely. Treatment with higher doses of vitamin D supplementation than would be used for osteoporosis (and possibly calcium if necessary) is often all that is required for the majority of people with osteomalacia caused by a vitamin D deficiency. For those who have the rarer forms of osteomalacia (either inherited or caused by kidney failure), more specific treatment and monitoring under the care of a specialist may be required.
Does osteoporosis mean you have “brittle bones”?
It’s not strictly correct to say that osteoporotic bone, which has lost its structure and strength, is “brittle”. Technically, “brittle bone” is actually very hard – so hard that it breaks or shatters very easily. This occurred with one of the very early osteoporosis drug treatments, called sodium fluoride, which turned out to actually make bones more, rather than less, likely to break.
Another problem with the word “brittle” is that it has been used for many years to describe a different medical condition, called “osteogenesis imperfecta (OI), often termed “brittle bone disease”. This disease is congenital (present from birth) and affects bone collagen, the protein that forms the framework for the bone structure. In OI, the collagen may be of poor quality or there may just not be enough to support the mineral structure of the bones. This makes fractures much more likely and often causes multiple and disabling fractures, especially in children.
It can be very confusing when the term “brittle bones” is used in relation to both conditions, so the osteoporosis world talks about “fragile bones” rather than “brittle bone”, and “fragility fractures”, to make this distinction clear.
I smoke and want to stop and have wondered about swapping to e-cigarettes. Can you tell me whether these have the same adverse effect on bone health as conventional tobacco cigarettes?
Smoking has been recognised for many years as one of the risk factors for osteoporosis that can be modified or changed for the better. The exact way smoking affects bone health is still poorly understood but studies certainly suggest that conventional cigarettes, which contain tobacco and nicotine, adversely affect bone health and increase the risk of fractures later in life. Recently e-cigarettes have become popular. They are battery-operated, cigarette-shaped devices that provide an alternative way to receive nicotine, the addictive chemical found in tobacco. The e-cigarettes work by heating a liquid cartridge containing nicotine, flavourings and other chemicals into an inhalable, smokeless vapour. There is a consensus view that e-cigarettes might in general be less harmful especially in terms of conditions that affect the lungs and the heart than smoking tobacco (which contains many other toxic additives). This does not mean, however, that smoking e-cigarettes is safe. E-cigarettes have not been studied for long enough to determine whether they increase a person’s risk of osteoporosis and fractures in the long run. However, as they contain nicotine, which has adverse effects on bone, it is likely that they will have some adverse effects also. Whether the risk is lower than compared to smoking conventional cigarettes is not known at this time. Several studies have suggested that the effects of smoking conventional cigarettes on bone health may be partially reversible and osteoporosis guidelines certainly encourage people to stop smoking. Although e-cigarettes are marketed as a smoking replacement device, some people do suggest that using them may help you to stop smoking, with the consequent benefits to bone health. Unfortunately there is currently no conclusive evidence that e-cigarettes are safe for long-term use, or are effective as a smoking cessation aid. There is also some concern that smoking e-cigarettes in public might result in smoking, in general, being seen as more acceptable again.
A plaster cast will usually be applied in hospital to stabilise the break and aid healing. A hospital stay will not usually be necessary. The plaster cast will stay on until the bone has healed, usually for about six weeks. You will be advised about appropriate exercises to help strengthen your muscles and get back to normal activities.
Occasionally, an operation may be needed to re-align and stabilise the bones. Sometimes, wires are used to hold the bones in position and a partial cast is applied in the operating theatre. After a few days, when the swelling has gone down, a full cast is applied.
A small proportion of people with wrist fractures may go on to develop longer-term problems, such as osteoarthritis of the wrist. Complex regional pain syndrome (CRPS) is a rare but painful complication of wrist fracture. To reduce your chance of developing CRPS, it is important to do the recommended exercises before and after the cast is removed. For more information, see our factsheet.
Broken hips most commonly occur in people over 75 years of age who fall directly onto their hip. An operation is normally required to fix or replace the upper end of the thigh bone that has broken (see photos opposite). Your surgeon will want to repair the break as soon as possible but this may be delayed if you have a urine or chest infection, low levels of red blood cells (anaemia) or heart problems. You will either have a general anaesthetic or an injection into your spine to completely numb the lower half of your body.
The quicker you get up after surgery, the more successful your recovery is likely to be as this reduces your risk of problems such as a chest infection and clotting issues. You will usually be up and out of bed the next day with the help of a physiotherapist and a walking frame and gradually become more mobile as the days progress. After the operation, you will have regular, strong pain-relieving injections or a patient-controlled analgesia pump, which provides a pain-relieving drug straight into a vein. This allows you to control your pain by giving yourself safe amounts of medicine.
If you were already quite frail before breaking your hip, you may need a period of rehabilitation after your operation so that you can go home safely. The length of stay in hospital can be between five days and three weeks. A physiotherapist should give you specific advice about appropriate exercises to help with your recovery.
Operation to mend a hip fracture
There are other fractures that may occur with osteoporosis, such as fractures of a rib, an upper arm or the pelvis. If you experience one of these, talk to your doctor or ask to see a physiotherapist for advice about what you can expect and also about appropriate exercises (or limits to your activities) to aid your recovery.
If you have suffered with a fracture, please find details for your local support group; they may be able to help.
Spinal compression fracture
The experience of compression fractures is varied. For some people, these fractures occur suddenly with severe and disabling pain but, for many, the compression of the bone is ‘silent’, causing little or no pain.
These are usually stable fractures so you do not need an operation and you do not need to wear a special spinal brace to keep your back immobile. In fact, it is important that you keep as mobile as you can to help to prevent problems such as chest infections, constipation and even blood clots. Keeping mobile will also help to maintain your muscle strength and reduce further pain problems. Taking a pain-relieving medication can help with the pain and will also help you to stay as active as you can. However, if pain is severe in the early stages, you may need to reduce your mobility for a while although this isn’t necessary to aid healing.
In the longer term, whether or not your spinal fractures are painful, you may notice you have lost some height or are beginning to get an outward curve at the top of your spine.
Many people recover well from painful compression fractures but some will go on to experience chronic (persistent) back pain due to the effects of the changes in spinal shape. Sometimes, these fractures can lead to being less active, having sleep problems, feeling emotionally low and reduced general health. Height loss and postural changes can cause shortness of breath and your stomach may feel squashed and bloated. This can make day-to-day living more difficult.
For hints and tips on how to overcome various problems associated with broken bones caused by osteoporosis, see below;
A compression fracture seems different from a normal broken bone so why is it painful and what can I expect?
It is still a broken bone in the sense that there is a break in the outermost layer. Nerves are therefore stimulated, sending signals to the spinal cord and up to your brain.
Often, during a fracture, blood vessels in the bone are torn and bleed and back muscles can go into spasm as they try to hold the broken bone together. These changes create further pressure on nerve endings. This immediate pain is often described as ‘acute pain’. You may experience it immediately when a bone breaks and it will usually lessen over the following six to twelve weeks as the injured tissue and bone heal.
Why am I still getting pain after my spinal fracture has healed?
Even though a fracture has healed, sometimes pain improves but doesn’t go away completely, with pain coming and going or occasionally becoming constant. Pain that lasts beyond the expected healing time, sometimes defined as longer than three months, is called persistent pain or ‘chronic pain’. If the fracture has healed, there will be other causes of the pain:
- Nerves leave the spinal cord and travel between the individual spinal bones to all areas of the body. It is possible for a spinal fracture to pinch or irritate one or more of these nerves, causing pain. Sometimes this pinching or irritation of the nerve carries on after healing because the bone has healed into a flattened or wedge shape. Occasionally, pain persists when nerves carrying pain signals have become overly sensitive and continue to ‘fire off’ pain signals even though the fracture has healed.
- Joints and ligaments, where spinal bones join together, are put under strain as they try to adapt to the new shape of the spine. Sometimes, arthritis in your back may be aggravated by the change in the natural curve of the spine caused by osteoporosis.
- Painful muscle spasms can happen with a new spinal fracture due to inflammation around the fracture and the altered stresses and strains on the back muscles caused by the new shape of the spine. However, unfortunately, when a spinal fracture has healed, these spasms may still occur because of ongoing muscle strain. Height loss and changes in the natural curves of the spine can over-stretch or shorten some back and torso (chest and abdominal) muscles. These may become easily tired when pulled and strained in ways they are not used to and may be prone to going into spasm. Typically, a spasm can happen when lifting an object or when pushing, pulling, bending or twisting, such as when using a vacuum cleaner. Occasionally, even a small movement can set off a muscle spasm. See here for ways to help with pain.