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Pain: What is normal pain after a fracture?

There's pain

and then there's

%$#@*! Pain

The one thing that everyone on the board wants to know about is Pain. Why do I have it? how long does it last? will it go away if I do this or that? what is normal? how do you cope? In response I would like to explain a few things about pain, how and why we feel it and what is normal and abnormal.

What is pain? What is the function of pain? Why does it hurt when you break a leg? "Normal" pain during healing of a fracture The Short and the Long of it
Abnormal pain        

What is pain?

That sounds like an airy fairy philosophical question but there is actually a very concrete answer. Pain is the sensation mediated by special nerves called pain fibres. If you stimulate these nerves electrically you get the sensation of pain even though there is no damage and nothing is permanently painful. The connection with your brain is interpreted as pain. So anything which makes those nerve endings fire off is felt as pain. Pain nerves are amongst the smallest in the body and they conduct impulses slowly. That is why there is an appreciable delay between the impact of a blow and the feeling of pain. Touch and position sense travel much faster. One of the other consequences is that pain nerve fibres are easily blocked by pressure and by local anaesthetics (freezing). If your hand "goes to sleep" the pain fibres are blocked but you can often feel things touching and moving. Another consequence of their small size is that pain nerve endings are very sensitive and easily fired off, so we feel pain when almost anything is wrong. Pain fibres are the first ones to grow back after a nerve injury so that the first sensation to return to a numb area is guess what!

What is the function of pain?

Pain is a warning. You might wonder why there is such an elaborate and pesky system. Some rare individuals have a  deficiency that means that they cannot feel pain. This lack leads to injuries and infections being ignored and getting out of hand. (see an account of one young man's problems) So the purpose of pain is to draw attention to a problem. In nature if an animal is hurt the main way of healing it to keep the injured part still. So pain alerts one and makes you want to keep everthing immobile - which with modern treatment may not be the best adaptation. What I am trying to say is that pain and pain response evolved in a situation where the only treatment was to crawl away and lick your wounds. Now we normally get medical treatment for severely injured legs and recovery from the injury may be faster and better if you move the limb early. So while pain is still an indication that there is something wrong, our innate response to it may not always be appropriate.

Why does it hurt when you break a leg?

As we saw in the previous paragraph the "purpose" of pain is to warn that something is wrong and to enforce rest. The mechanism of pain is another issue. Nerves large and small run in all the tissues of the body including bones, muscles, ligaments and tendons. When you break something you break the nerves which are in that tissue. The ruptured nerve endings are extremely sensitive and the pain fibres are the most easily stimulated. Any time you move the injured area or contract muscles which compress it, the "raw" nerve endings fire off - ouch! Sometimes the broken leg is also distorted and this will stretch the nerve endings. So to relieve the acute pain from a broken bone, first aid involves straightening and splinting the limb so that the broken pieces do not move.

"Normal" pain during healing of a fracture

Once a fracture is set and immobilized the pain from moving the broken pieces no longer applies. Since OS are bone oriented doctors we tend to think that because the bone doesn't hurt so much there is no major pain problem. But of course there is a problem and it comes from many sources.

  1. Movement. Often the fracture fragments are not completely immobilized. This is especially true in a cast. A cast is designed to keep the fragments lined up and in the correct position but it cannot prevent micromovement at the fracture site. This micromovement doesn't prevent healing but it does hurt, by the same mechanism that the original injury hurt - stimulation of damaged nerve endings.

  2. Soft tissue injury. The force that breaks the bone and the sharp edges of the broken bone itself will most often cause bruising and laceration of the muscles, tendons and ligaments in the area. These  structures are not immobilized by the orthopaedic treatment, be it casts, splints or internal fixation. They too have torn nerve endings and these nerve endings are sensitive.

  3. Surgery. Cutting the skin and muscle over a fracture in order to expose it so it can be reduced and "fixed" damages the soft tissue also.

  4. Inflammation. Even if the fracture is immobile and the soft tissue injury is minimal the area still hurts. This is because inflammation is the first stage of healing. Inflammation is the process by which the blood supply to the area is increased to mobilize resources, the dead, injured and non functioning tissue is removed and the stage is set for new reparative tissue to start growing. Inflammation is started when histamine is released from damaged cells. This initiates a complex series of changes including

    • Dilatation of blood vessels increasing the overall blood supply
    • Blood vessels become "leaky".
    • White blood cells migrate out of the vessels and start mopping up detritus
    • Increased tissue fluid
    • New blood vessels grow into the volume occupied by blood clot and necrotic tissue
    • Fibroblasts (cells which lay down collagen fibers) arrive with the new blood vessels and lay down a collagen matrix (scar)

    If you look carefully at all these changes you will realize they all have one thing in common. They increase the volume of the injured area. In other words the region swells. This swelling is both inevitable and part of the healing process. However it hurts. Some parts of the inflammatory process are inherently painful, like histamine release. Swelling is sore because it puts pressure on the damaged nerve endings and makes them fire off.

  5. Circulatory changes. The increased supply of blood is normal but the problem of swelling is often increased by damage to the drainage system of the limb. The veins and lymphatics that take fluid away from the limb are often injured so there is no way for the blood and tissue fluid to be drained away. This compounds the problem of swelling.
  6. Loss of the muscle pump. The big veins of the leg have valves in them to allow blood to move up the leg but not back down again. When the muscles contract the veins are flattened and blood is pumped towards the heart. When the muscles are immobilized by pain this mechanism doesn't work and the limb swells even more.
  7. Bruising. Tissues that weren't injured may be affected by bleeding from the injury that tracks away from the fracture and bathes tendons and ligaments in blood. The blood coagulates and an inflammatory process is set up to clear away the blood clot. This may be quite remote from the original injury.

So during the inflammatory period of healing which lasts for 2-3 weeks following injury much of the pain is related to swelling and measures to relieve swelling are the most effective ways to manage pain. These include elevation, ice, gentle movment of the uninjured muscles and gentle massage to improve the circulation. Wheras in nature, movement is a bad idea because the fracture will be moved, after immobilization of the fracture movement is a good idea because it improves the circulation, nourishes the joints and prevents the tissues from scarring and sticking together.

The acute inflammation settles within a few weeks and the scar tissue transforms itself into bone in the area of the fracture. During this period scar also develops wherever there has been bleeding or bruising. Scar tissue tends to bind tendons and ligaments together so that they do not glide normally. As normal function returns to the joints and the muscles start to move again the scar tissue has to stretch and this hurts and may even provoke a return of swelling.

The Short and the Long of it

The best news is that the pain due to fracture movement and to inflammation is shortlived. Fractures stick together and the inflammatory process settles down within 2-3 weeks depending on the severity of the injury and the way it has been treated. However, the remaining healing processes are also uncomfortable - remodelling of scar and bone tissue, stretching of scar to allow full movement, recovery of muscle strength and function are all uncomfortable to some degree. Stretching of scar tissue can be severely painful. These processes go on for up to 18 months after an uncomplicated normal injury. The feeling that your leg isn't normal may last that long - even if it is headed back to normality.

Abnormal pain

to be continued

This topic is complicated, difficult, sometimes emotional and very personal. Your comments and embellishments would be most welcome and likely to add a lot to this somewhat dry and detached account!

Myles Clough MD OS Posted 5/1/02


From: Guz

About 6 weeks ago I suffered a "very bad" fracture dislocation of the right ankle, and my pain situation has been unusual in the best way.

Right when it happened (I was roller skating), I fell to the floor, and reached down to see if it was a compound fracture (bone exposed).

Thankfully it was not, but the geometry of my ankle revealed an obvious fracture.

Here's the odd part: my heart-rate didn't increase (in fact, it seemed to slow), I became very lucid and relaxed, and I didn't really feel much pain (unless I tried to move at all).

After ORIF, I've had little pain (with the exception of 1 specific area [around the breaking point]) which I presume is healing ligament).

Was it some mild form of shock?

I have broken other bones (shoulder and hand) which I found to be much more painful.

Feeling very fortunate given the circumstances,

Guz


From: Mark

ya I just broke my fibula yesterday...didnt hurt very much at all...today however is a different story...the waves of pain are not fun...till the percs kick in...I have broken my scafoid (wrist) before and it wasnt nearly as painful as this i think...although i am relatively early on in the healing process


From: Andrew

Immediately after breaking both tib and fib I suffered little pain. After an initial cast was replaced by a larger one the pain multiplied. I get little sleep and find only by raising my leg high in the air does the pain abate. As I write I\'m trying to keep the leg down for a bit, the pain is almost so bad I can\'t write but not quite...the sensation of the leg swelling slowly inside the cast is even worse.


From: eilidh

i had very little pain as well. i broke my fibula last week, and granted when i did it i was drunk, but i managed to walk home on it thinking it was a bad sprain and in the morning it was only sore if i put to much pressure onto it so i could easly hobble around my flat however with a majour limp. when i got the cast on it wqas fine as long as i could keep it televated for when i wasnt using my leg, and the only majour pain i have had is in the mornings wheni get up and the blood rushes back into the joint, that hurts, its a bit sore today cos i was doing a lot of runnign around yesterday and i didnt have much chance to rest it, but even still, its not sore enough to take a pain killer, and i have had no apin medication


From: eilidh

i had very little pain as well. i broke my fibula last week, and granted when i did it i was drunk, but i managed to walk home on it thinking it was a bad sprain and in the morning it was only sore if i put to much pressure onto it so i could easly hobble around my flat however with a majour limp. when i got the cast on it wqas fine as long as i could keep it televated for when i wasnt using my leg, and the only majour pain i have had is in the mornings wheni get up and the blood rushes back into the joint, that hurts, its a bit sore today cos i was doing a lot of runnign around yesterday and i didnt have much chance to rest it, but even still, its not sore enough to take a pain killer, and i have had no apin medication


From: Michael

I broke my tibia and fibia 7 days ago. I had surgery the same day and the Doctor put a pin in my tibia and put my leg in a splint. I have been walking around the house this week on crutches and didn't have much pain until two days ago.

After that point, everytime I get up off the couch or out of the bed, I feel fluid (I assume blood) running down into my leg and the leg swelling. I can see my toes (of the broken leg) turning light - red. There is a build up of pressure and thus pain in the leg which subsides as soon as I lie back down. After reading this site about pain, I see that this should only last 2-3 weeks while the healing process is occuring - thank God!

I just wonder if I am doing any damage when I do stand up and move around on crutches. I need to get around to eat and do other basic things, so I hope not, but would like to know. Also, I wonder why it started only two days ago...

Thank you for putting this site together to help me understand what is happening to my leg. It has been very helpful!!


From: Bamber

I broke my tib and fib playing football and I was in absolute agony for at least half an hour, once in the cast the pain wasn't too bad, i found taking paraceatamol 4 times a day really helped, espescially before bed. Also ask your doctor about anti-inflamatory drugs, they're the business


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