Bone fracture

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Bone fracture

Other names broken bone, bone break

Internal and external views of an arm with a compound

fracture, both before and after surgery

Specialty Orthopedics

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition

in which there is a partial or complete break in the continuity of the bone. In more
severe cases, the bone may be broken into several pieces.[1] A bone fracture may be
the result of high force impact or stress, or a minimal trauma injury as a result of
certain medical conditions that weaken the bones, such
as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the
fracture is then properly termed a pathologic fracture.[2]

Contents

 1Signs and symptoms

o 1.1Complications
 2Pathophysiology
o 2.1Effects of smoking
 3Diagnosis
o 3.1Classification
 3.1.1Mechanism
 3.1.2Soft-tissue involvement
 3.1.3Displacement
 3.1.4Fracture pattern
 3.1.5Fragments
  3.1.6Anatomical location
o 3.2OTA/AO classification
o 3.3Classifications named after people
 4Prevention
 5Treatment
o 5.1Pain management
o 5.2Immobilization
o 5.3Surgery
o 5.4Other
 6Children
 7See also
 8References
 9External links

Signs and symptoms[edit]

Although bone tissue itself contains no nociceptors, bone fracture is painful for
several reasons:[3]

 Breaking in the continuity of the periosteum, with or

without similar discontinuity in endosteum, as both
contain multiple pain receptors.
 Edema and hematoma of nearby soft tissues caused by
ruptured bone marrow evokes pressure pain.
 Involuntary muscle spasms trying to hold bone
fragments in place.

Damage to adjacent structures such as nerves, muscles or blood vessels, spinal

cord, and nerve roots (for spine fractures), or cranial contents (for skull fractures)
may cause other specific signs and symptoms.
Complications[edit]

An old fracture with nonunion of the fracture fragments

Some fractures may lead to serious complications including a condition known
as compartment syndrome. If not treated, eventually, compartment syndrome may
require amputation of the affected limb. Other complications may include non-union,
where the fractured bone fails to heal or mal-union, where the fractured bone heals
in a deformed manner. One form of malunion is the malrotation of a bone, which is
especially common after femoral and tibial fractures.
Complications of fractures may be classified into three broad groups, depending
upon their time of occurrence. These are as follows –

1. Immediate complications – occurs at the time of the

fracture.
2. Early complications – occurring in the initial few days
after the fracture.
3. Late complications – occurring a long time after the
fracture.

Immediate complications Early complications Late complications

Systemic

 Hypovolaemic shock Imperfect union of the

 ARDS – Adult respiratory fracture
distress syndrome
Systemic
 Fat embolism syndrome  Delayed union
 Deep vein thrombosis  Non union
 Hypovolaemic shock
 Pulmonary syndrome  Mal union
 Aseptic traumatic fever  Cross union
 Sepsis (in open fracture )
 Crush syndrome
Others
Local  Avascular necrosis
Local  Shortening
 Injury to major vessels
 Joint stiffness
 Injury to muscles and
 Infection  Sudeck's dystrophy
tendons
 Compartment syndrome  Osteomyelitis
 Injury to joints
 Ischaemic contracture
 Injury to viscera
 Myositis ossificans
 Osteoarthritis

Pathophysiology[edit]
Main article: Bone healing
The natural process of healing a fracture starts when the injured bone and
surrounding tissues bleed, forming a fracture hematoma. The blood coagulates to
form a blood clot situated between the broken fragments. Within a few days, blood
vessels grow into the jelly-like matrix of the blood clot. The new blood vessels
bring phagocytes to the area, which gradually removes the non-viable material. The
blood vessels also bring fibroblasts in the walls of the vessels and these multiply and
produce collagen fibres. In this way, the blood clot is replaced by a matrix of
collagen. Collagen's rubbery consistency allows bone fragments to move only a
small amount unless severe or persistent force is applied.
At this stage, some of the fibroblasts begin to lay down bone matrix in the form of
collagen monomers. These monomers spontaneously assemble to form the bone
matrix, for which bone crystals (calcium hydroxyapatite) are deposited in amongst, in
the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and
transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is
dissolved out of bone, it becomes rubbery. Healing bone callus on average is
sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in
children. This initial "woven" bone does not have the strong mechanical properties of
mature bone. By a process of remodelling, the woven bone is replaced by mature
"lamellar" bone. The whole process may take up to 18 months, but in adults, the
strength of the healing bone is usually 80% of normal by 3 months after the injury.
Several factors may help or hinder the bone healing process. For
example, tobacco smoking hinders the process of bone healing,[4] and adequate
nutrition (including calcium intake) will help the bone healing process. Weight-
bearing stress on bone, after the bone has healed sufficiently to bear the weight,
also builds bone strength.
Although there are theoretical concerns about NSAIDs slowing the rate of healing,
there is not enough evidence to warrant withholding the use of this type analgesic in
simple fractures.[5]
Effects of smoking[edit]
Smokers generally have lower bone density than non-smokers, so they have a much
higher risk of fractures. There is also evidence that smoking delays bone healing.[6]

Diagnosis[edit]
Radiography to identify possible fractures after a knee injury

A bone fracture may be diagnosed based on the history given and the physical
examination performed. Radiographic imaging often is performed to confirm the
diagnosis. Under certain circumstances, radiographic examination of the nearby
joints is indicated in order to exclude dislocations and fracture-dislocations. In
situations where projectional radiography alone is insufficient, Computed
Tomography (CT) or Magnetic Resonance Imaging (MRI) may be indicated.
Classification[edit]
"Compound Fracture" redirects here. For the 2013 horror film, see Compound
Fracture (film).
Compare healthy bone with different types of fractures:
(a) closed fracture
(b) open fracture
(c) transverse fracture
(d) spiral fracture
(e) comminuted fracture
(f) impacted fracture
(g) greenstick fracture
(h) oblique fracture

Open ankle fracture with luxation

Periprosthetic fracture of left femur

In orthopedic medicine, fractures are classified in various ways. Historically they are
named after the physician who first described the fracture conditions, however, there
are more systematic classifications as well.
They may be divided into stable versus unstable depending on the likelihood that
they may shift further.
Mechanism[edit]

Traumatic fracture – This is a fracture due to sustained


trauma. e.g., fractures caused by a fall, road traffic
accident, fight, etc.
 Pathologic fracture – A fracture through a bone that has
been made weak by some underlying disease is called
pathological fracture. e.g., a fracture through a bone
weakened by metastasis. Osteoporosis is the most
common cause of pathological fracture.
 Periprosthetic fracture – This is a fracture at the point of
mechanical weakness at the end of an implant
Soft-tissue involvement[edit]

 Closed fractures are those in which the overlying skin is

intact
 Open/compound fractures involve wounds that
communicate with the fracture, or where
fracture hematoma is exposed, and may thus expose
bone to contamination. Open injuries carry a higher risk
of infection.
o Clean fracture
o Contaminated fracture
Displacement[edit]
  Non-displaced
 Displaced
o Translated, or ad latus, with sideways
displacement.[7]
o Angulated
o Rotated
o Shortened
Fracture pattern[edit]

 Linear fracture: A fracture that is parallel to the bone's

long axis
 Transverse fracture: A fracture that is at a right angle to
the bone's long axis
 Oblique fracture: A fracture that is diagonal to a bone's
long axis (more than 30°)
 Spiral fracture: A fracture where at least one part of the
bone has been twisted
 Compression fracture/wedge fracture: usually occurs in
the vertebrae, for example when the front portion of
a vertebra in the spine collapses due to osteoporosis (a
medical condition which causes bones to become brittle
and susceptible to fracture, with or without trauma)
 Impacted fracture: A fracture caused when bone
fragments are driven into each other
 Avulsion fracture: A fracture where a fragment of bone
is separated from the main mass
Fragments[edit]

 Incomplete fracture: Is a fracture in which the bone

fragments are still partially joined, in such cases, there
is a crack in the osseous tissue that does not completely
traverse the width of the bone.
 Complete fracture: Is a fracture in which bone fragments
separate completely.
 Comminuted fracture: Is a fracture in which the bone
has broken into several pieces.
Anatomical location[edit]
An anatomical classification may begin with specifying the involved body part, such
as the head or arm, followed with more specific localization. Fractures that have
additional definition criteria than merely localization often may be classified as
subtypes of fractures, such as a Holstein-Lewis fracture being a subtype of
a humerus fracture. Most typical examples in an orthopaedic classification given in
the previous section cannot be classified appropriately into any specific part of an
anatomical classification, however, as they may apply to multiple anatomical fracture
sites.

 Skull fracture
o Basilar skull fracture
 o Blowout fracture – a fracture of the walls or floor of
the orbit
o Mandibular fracture
o Nasal fracture
o Le Fort fracture of skull – facial fractures involving
the maxillary bone and surrounding structures in a
usually bilateral and either horizontal, pyramidal, or
transverse way.
 Spinal fracture
o Cervical fracture
 Fracture of C1, including Jefferson fracture
 Fracture of C2, including Hangman's fracture
 Flexion teardrop fracture – a fracture of the
anteroinferior aspect of a cervical vertebral
o Clay-shoveler fracture – fracture through the spinous
process of a vertebra occurring at any of the lower
cervical or upper thoracic vertebrae
o Burst fracture – in which a vertebra breaks from a
high-energy axial load
o Compression fracture – a collapse of a vertebra,
often in the form of wedge fractures due to larger
compression anteriorly
o Chance fracture – compression injury to the anterior
portion of a vertebral body with concomitant
distraction injury to posterior elements
o Holdsworth fracture – an unstable
fracture dislocation of the thoracolumbar junction of
the spine
 Rib fracture
 Sternal fracture
 Shoulder fracture
o Clavicle fracture
o Scapular fracture
 Arm fracture
o Humerus fracture (fracture of upper arm)
 Supracondylar fracture
 Holstein-Lewis fracture – a fracture of
the distal third of the humerus resulting
in entrapment of the radial nerve
o Forearm fracture
 Ulnar fracture
 Monteggia fracture – a fracture of the
proximal third of the ulna with the dislocation
of the head of the radius
 Hume fracture – a fracture of
the olecranon with an
associated anterior dislocation of the radial
head
  Radius fracture
 Essex-Lopresti fracture – a fracture of
the radial head with concomitant dislocation
of the distal radio-ulnar joint with disruption of
the interosseous membrane [8]
 Distal radius fracture
 Galeazzi fracture – a fracture of the
radius with dislocation of the distal
radioulnar joint
 Colles' fracture – a distal fracture of the
radius with dorsal (posterior)
displacement of the wrist and hand
 Smith's fracture – a distal fracture of the
radius with volar (ventral) displacement of
the wrist and hand
 Barton's fracture – an intra-articular
fracture of the distal radius with
dislocation of the radiocarpal joint
 Hand fracture
o Scaphoid fracture
o Rolando fracture – a comminuted intra-
articular fracture through the base of the
first metacarpal bone
o Bennett's fracture – a fracture of the base of the first
metacarpal bone which extends into
the carpometacarpal (CMC) joint [9]
o Boxer's fracture – a fracture at the neck of
a metacarpal
 Pelvic fracture
o Fracture of the hip bone
o Duverney fracture – an isolated pelvic fracture
involving only the iliac wing
 Femoral fracture
o Hip fracture (anatomically a fracture of
the femur bone and not the hip bone)
 Patella fracture
 Crus fracture
o Tibia fracture
 Pilon fracture
 Tibial plateau fracture
 Bumper fracture – a fracture of
the lateral tibial plateau caused by a
forced valgus applied to the knee
 Segond fracture – an avulsion fracture of
the lateral tibial condyle
 Gosselin fracture – a fractures of the
tibial plafond into anterior and posterior
fragments [10]
  Toddler's fracture – an undisplaced and spiral
fracture of the distal third to distal half of the
tibia [11]
o Fibular fracture
 Maisonneuve fracture – a spiral fracture of the
proximal third of the fibula associated with a tear
of the distal tibiofibular syndesmosis and the
interosseous membrane
 Le Fort fracture of ankle – a vertical fracture of
the antero-medial part of
the distal fibula with avulsion of the anterior
tibiofibular ligament [10]
 Bosworth fracture – a fracture with an associated
fixed posterior dislocation of the distal fibular
fragment that becomes trapped behind
the posterior tibial tubercle; the injury is caused
by severe external rotation of the ankle [12]
o Combined tibia and fibula fracture
 Trimalleolar fracture – involving the lateral
malleolus, medial malleolus, and the distal
posterior aspect of the tibia
 Bimalleolar fracture – involving the lateral
malleolus and the medial malleolus
 Pott's fracture
 Foot fracture
o Lisfranc fracture – in which one or all of
the metatarsals are displaced from the tarsus[13]
o Jones fracture – a fracture of the proximal end of
the fifth metatarsal
o March fracture – a fracture of the distal third of one
of the metatarsals occurring because of recurrent
stress
o Calcaneal fracture - a fracture of the calcaneus (heel
bone)
OTA/AO classification[edit]
Main article: Müller AO Classification of fractures
The Orthopaedic Trauma Association Committee for Coding and Classification
published its classification system [14] in 1996, adopting a similar system to the
1987 AO Foundation system.[15] In 2007, they extended their system,[16] unifying the
two systems regarding wrist, hand, foot, and ankle fractures.
Classifications named after people[edit]
Main category: Orthopedic classifications
A number of classifications are named after the person (eponymous) who developed
it.

 "Denis classification" for spinal fractures [17]

  "Frykman classification" for forearm fractures (fractures
of radius and ulna)
 "Gustilo open fracture classification" [18]
 "Letournel and Judet Classification" for Acetabular
fractures [19]
 "Neer classification" for humerus fractures [20][21]
 Seinsheimer classification, Evans-Jensen
classification, Pipkin classification, and Garden
classification for hip fractures

Prevention[edit]
Both high- and low-force trauma can cause bone fracture injuries.[22][23] Preventive
efforts to reduce motor vehicle crashes, the most common cause of high-force
trauma, include reducing distractions while driving.[24]Common distractions are driving
under the influence and texting or calling while driving, both of which lead to an
approximate 6-fold increase in crashes.[24] Wearing a seatbelt can also reduce the
likelihood of injury in a collision.[24]
A common cause of low-force trauma is an at-home fall.[22][23] When considering
preventative efforts, the National Institute of Health (NIH) examines ways to reduce
the likelihood of falling, the force of the fall, and bone fragility.[25] To prevent at-home
falls they suggest keeping cords out of high-traffic areas where someone could trip,
installing handrails and keeping stairways well-lit, and installing an assistive bar near
the bathtub in the washroom for support.[25] To reduce the impact of a fall the NIH
recommends to try falling straight down on your buttocks or onto your
hands.[25] Finally, taking calcium vitamin D supplements can help strengthen your
bones.[25]

Treatment[edit]

X-ray showing the proximal portion of a fractured tibia with an intramedullary nail
The surgical treatment of mandibular angle fracture; fixation of the bone fragments by the plates,
the principles of osteosynthesis are stability (immobility of the fragments that creates the
conditions for bones coalescence) and functionality

Proximal femur nail with locking and stabilisation screws for treatment of femur fractures of left
thigh

Treatment of bone fractures are broadly classified as surgical or conservative, the

latter basically referring to any non-surgical procedure, such as pain management,
immobilization or other non-surgical stabilization. A similar classification
is open versus closed treatment, in which open treatment refers to any treatment in
which the fracture site is opened surgically, regardless of whether the fracture is
an open or closed fracture.
Pain management[edit]
In arm fractures in children, ibuprofen has been found to be as effective as a
combination of acetaminophen and codeine.[26]
Immobilization[edit]
Since bone healing is a natural process that will occur most often, fracture treatment
aims to ensure the best possible function of the injured part after healing. Bone
fractures typically are treated by restoring the fractured pieces of bone to their
natural positions (if necessary), and maintaining those positions while the bone
heals. Often, aligning the bone, called reduction, in a good position and verifying the
improved alignment with an X-ray is all that is needed. This process is extremely
painful without anaesthesia, about as painful as breaking the bone itself. To this end,
a fractured limb usually is immobilized with a plaster or fibreglass cast or splint that
holds the bones in position and immobilizes the joints above and below the fracture.
When the initial post-fracture oedema or swelling goes down, the fracture may be
placed in a removable brace or orthosis. If being treated with surgery, surgical nails,
screws, plates, and wires are used to hold the fractured bone together more directly.
Alternatively, fractured bones may be treated by the Ilizarov methodwhich is a form
of an external fixator.
Occasionally smaller bones, such as phalanges of the toes and fingers, may be
treated without the cast, by buddy wrapping them, which serves a similar function to
making a cast. A device called a Suzuki frame may be used in cases of deep,
complex intra-articular digit fractures.[27] By allowing only limited movement,
immobilization helps preserve anatomical alignment while enabling callus formation,
toward the target of achieving union.
Splinting results in the same outcome as casting in children who have a distal radius
fracture with little shifting.[28]
Surgery[edit]
Surgical methods of treating fractures have their own risks and benefits, but usually
surgery is performed only if conservative treatment has failed, is very likely to fail, or
likely to result in a poor functional outcome. With some fractures such as hip
fractures (usually caused by osteoporosis), surgery is offered routinely because non-
operative treatment results in prolonged immobilisation, which commonly results in
complications including chest infections, pressure sores, deconditioning, deep vein
thrombosis (DVT), and pulmonary embolism, which are more dangerous than
surgery. When a joint surface is damaged by a fracture, surgery is also commonly
recommended to make an accurate anatomical reduction and restore the
smoothness of the joint.
Infection is especially dangerous in bones, due to the recrudescent nature of bone
infections. Bone tissue is predominantly extracellular matrix, rather than living cells,
and the few blood vessels needed to support this low metabolism are only able to
bring a limited number of immune cells to an injury to fight infection. For this reason,
open fractures and osteotomies call for very careful antiseptic procedures
and prophylactic use of antibiotics.
Occasionally, bone grafting is used to treat a fracture.
Sometimes bones are reinforced with metal. These implants must be designed and
installed with care. Stress shielding occurs when plates or screws carry too large of a
portion of the bone's load, causing atrophy. This problem is reduced, but not
eliminated, by the use of low-modulus materials, including titanium and its alloys.
The heat generated by the friction of installing hardware can accumulate easily and
damage bone tissue, reducing the strength of the connections. If dissimilar metals
are installed in contact with one another (i.e., a titanium plate with cobalt-
chromium alloy or stainless steel screws), galvanic corrosion will result. The
metal ions produced can damage the bone locally and may cause systemic effects
as well.
Other[edit]
A Cochrane review of low-intensity pulsed ultrasound to speed healing in newly
broken bones found insufficient evidence to justify routine use. [29] Other reviews have
found tentative evidence of benefit.[30] It may be an alternative to surgery for
established nonunions.[31]
Vitamin D supplements combined with additional calcium marginally reduces the risk
of hip fractures and other types of fracture in older adults; however, vitamin D
supplementation alone did not reduce the risk of fractures.[32]

Children[edit]
Main article: Child bone fracture
In children, whose bones are still developing, there are risks of either a growth plate
injury or a greenstick fracture.

 A greenstick fracture occurs due to mechanical failure

on the tension side. That is since the bone is not so
brittle as it would be in an adult, it does not completely
fracture, but rather exhibits bowing without complete
disruption of the bone's cortex in the surface opposite
the applied force.
 Growth plate injuries, as in Salter-Harris fractures,
require careful treatment and accurate reduction to
make sure that the bone continues to grow normally.
 Plastic deformation of the bone, in which the bone
permanently bends, but does not break, also is possible
in children. These injuries may require
an osteotomy (bone cut) to realign the bone if it is fixed
and cannot be realigned by closed methods.
 Certain fractures mainly occur in children, including
fracture of the clavicle and supracondylar fracture of the
humerus.[citation needed]

See also[edit]
 Stress fracture
 Distraction osteogenesis
 Rickets
 Catagmatic
 H. Winnett Orr, U.S. Army surgeon who
developed Orthopedic plaster casts

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External links[edit]
Classification D

 ICD-10: Sx2 (where x=0–9 depending on the location of the fractur

 ICD-9-CM: 829
 MeSH: D050723
 DiseasesDB: 4939

External resources  MedlinePlus: 000001

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media related to Bone
fractures.

 Authoritative information in orthopaedic

surgery American Association of Orthopedic Surgeons
(AAOS)
 Radiographic Atlas of Fracture
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Fractures and cartilage injuries (Sx2, 800–829)

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 Trauma

Categories:
 Bone fractures
 Acute pain
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