- Clinical science
General principles of fractures
Summary
A fracture is a partial or complete interruption in the continuity of bone. The most common causes are trauma and 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:
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Anatomy
- Location: affected bone (proximal, distal)
- Position: diaphysis, metaphysis, epiphysis
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Extent
- Complete
- Incomplete
- Orientation: transverse, oblique, spiral
- Displacement: nondisplaced, displaced, angulated
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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
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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
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
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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
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Conditions:
-
CT/MRI (not routine)
- Indications: preoperative planning for complicated fractures, assessment of associated injuries, and inconclusive x-ray findings.
-
X-ray
References:[6][7]
Treatment
General approach
- Wound care
- Pain management (e.g., non-opioid analgesics, opioids)
-
Fracture care (conservative or surgical)
- Anatomic reduction
- Fixation
- 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
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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.