General principles of fractures

Last updated: November 29, 2022

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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.

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

References:[1]

Fracture classification

Based on the following characteristics:

  • Anatomy
  • Extent
    • Complete
    • Incomplete
  • Orientation: transverse, oblique, spiral
  • Displacement
    • Rotated: rotation around the longitudinal axis
    • Angulated: angulation of the axis
    • Translated: lateral movement of the bone fragments
    • Longitudinal displacement of bone fragments
      • Distraction: elongation
      • Impaction: shortening
  • Fragmentation
    • Comminuted fracture: more than two fracture lines resulting in multiple bone fragments
    • Segmental fracture: two fracture lines with a bone fragment between the proximal and distal portions of the bone
  • Soft tissue involvement
    • Closed fracture (simple fracture; does not come into contact with the outside environment)
    • Open fracture
  • Growth plate involvement (pediatric fractures): Salter-Harris fractures

Common fractures in children

See “Pediatric fractures” for details.

Common fractures in adults

Pathologic fracture

Open fracture [2]

Operative management of open fractures should not be delayed because of the high risk of wound infection.

Other fractures

  • 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 the site of injury

Clinical assessment

Imaging

  • X-ray
    • Requirements
      • 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): indicated in preoperative planning for complicated fractures, assessment of associated injuries, and inconclusive x-ray findings

General approach

Conservative fracture management

  • Indications
  • Procedure: closed reduction; and, if necessary, immobilization with a cast or splint of the fractured bone and adjacent joints

Surgical fracture management

  • Indications
    • Open fractures
    • Unstable fractures (e.g., extremity fractures, pelvic 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

Acute complications

Long-term complications

Nonunion [3]

Complications due to immobilization

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

  1. Sop JL, Sop A. Open Fracture Management. StatPearls. 2021 .
  2. Wick JY. Spontaneous fracture: multiple causes. Consult Pharm. 2009; 24 (2): p.100-113. doi: 10.4140/TCP.n.2009.100 . | Open in Read by QxMD
  3. Stewart SK. Fracture Non-Union: A Review of Clinical Challenges and Future Research Needs.. Malaysian orthopaedic journal. 2019; 13 (2): p.1-10. doi: 10.5704/MOJ.1907.001 . | Open in Read by QxMD

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