Summary

A fracture is a partial or complete interruption in the continuity of bone. The most common cause is trauma, followed by diseases (e.g., osteoporosis) that result in weakened bone structure. The latter results in pathologic fractures, which are fractures that would not usually occur if the bone structure was not weakened. Open fractures, in which the bone is exposed due to severe soft tissue injury, are associated with a significant risk of infection and poor wound healing. Fracture management can be conservative (e.g., cast or splint) or surgical, and generally involves anatomic reduction, fixation, and/or immobilization. Complications include acute nerve and vascular injury and compartment syndrome, as well as long-term complications such as avascular necrosis and nonunion.

Etiology

Trauma: mechanical stress and/or loading
Weakened bone structure: osteoporosis, bone tumors, metastasis, Paget disease

References:^[1]

Classification

Fracture classification is based on the following:

Anatomy
- Location: affected bone (proximal, distal)
- Position: diaphysis, metaphysis, epiphysis
Extent
- Complete
- Incomplete
Orientation: transverse, oblique, spiral
Displacement: nondisplaced, displaced, angulated
Fragmentation
- Comminuted fracture
- Segmental fracture
Soft tissue involvement
- Closed fracture (simple fracture)
- Open fracture
Growth plate involvement (pediatric fractures): Salter-Harris fractures

References:^[2]^[3]

Overview of common fractures

Common fractures in children

See “Pediatric fractures” for details.

Common fractures in adults

Pathologic fracture
Open fracture
- A fracture in which bone fragments break through the skin
- Secondary to trauma
- Associated with significant soft tissue injury and an increased risk of complications (infection, poor healing)
Stress fracture
Forearm fractures
- Colles fracture: distal radius ± distal ulna
- Smith fracture: distal radius
- Monteggia fracture: proximal one-third of the ulna and dislocation of the radial head
- Galeazzi fracture: distal radial shaft and dislocation of the distal radioulnar joint
Boxer's fracture
Scaphoid fracture
Ankle fracture
Tibial fracture
Femoral shaft fracture
Femoral neck fracture
Pelvic fracture
Vertebral fractures (including compression fractures)

References:^[2]^[4]^[5]

Clinical features

Pain, redness, and swelling at the site of injury
Deformity and axis deviation
Bone fragments penetrating the skin
Palpable step-off or gap
Bone crepitus
Concomitant soft tissue injuries
Neurovascular compromise below site of injury

Diagnostics

Clinical assessment
- Assess for signs of a fracture and concomitant injuries
- Assess for neurovascular compromise and compartment syndrome with the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis and poikilothermia
Imaging
- X-ray
  - Conditions:
    - 2 views
    - 2 joints (if limb fracture)
    - 2 times (prereduction and postreduction)
  - Radiographic signs of a fracture include a radiolucent fracture line and cortical disruption
  - Describe fracture based on the anatomic location, alignment , angulation, and articular involvement (see “Classification” above for details)
  - X-ray imaging has a low sensitivity for detecting stress fractures
- CT/MRI (not routine)
  - Indications: preoperative planning for complicated fractures, assessment of associated injuries, and inconclusive x-ray findings.

References:^[6]^[7]

Treatment

General approach

Wound care
Pain management (e.g., non-opioid analgesics, opioids)
Fracture care (conservative or surgical)
1. Anatomic reduction
2. Fixation
3. Immobilization

Conservative fracture management

Indications
- Stable fractures
- Mainstay management of pediatric fractures (See “Pediatric fractures” for details)
Procedure: closed reduction; and, if necessary, immobilization; of the fractured bone and adjacent joints with a cast or splint
See “Conservative treatment of fractures” for details

Surgical fracture management

Indications
- Open fractures
- Unstable fractures
- Severe displacements (e.g., rotational deformities) and displaced fragments
- Inadequate manual reduction and fixation
Procedure: anatomic reduction of the fracture and subsequent fixation and immobilization using:
- External fixation: immobilizing a fracture using pins or screws that are secured outside the skin or
- Internal fixation: immobilizing a fracture using implants (e.g., plates, screws, wires)
- Open reduction and internal fixation: realignment of the ends of a fracture, and stabilization of the fracture using implants (e.g., plates, screws, wires)

References:^[6]

Complications

Acute complications
- Neurologic and vascular injury (eg. bleeding, hematoma, seroma)
- Compartment syndrome
- Wound infection, osteomyelitis
Long-term complications
- Avascular necrosis
- Complex regional pain syndrome
- Post-traumatic osteoarthritis
- Joint stiffness/contracture
- Joint instability
- Heterotopic ossification
- Children: growth disturbances after growth plate injury (→ Salter-Harris fracture)
- Nonunion: incomplete healing of a fracture which results in the creation of a false joint (pseudarthrosis)
  - Clinical features: pain, swelling, limited weight-bearing capacity, and reduced range of motion persisting after the normal duration of healing (usually 6–9 months)
  - Treatment: debridement and resection, osteosynthesis (fixation), antibiotics in the case of infected nonunion
Complications due to immobilization
- Thrombosis, pulmonary embolism
- Infections (e.g., pneumonia, urinary tract infection)

References:^[3]^[8]

We list the most important complications. The selection is not exhaustive.