FRACTURE

Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in
the world. Bones also protect some body parts, and the bone marrow is the production center for blood products.

Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the
influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while
calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand
those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another.
The integrity of the bone has been lost and the bone structure fails.

Broken bones hurt for a variety of reasons including:

 The nerve endings that surround bones contain pain fibers and and these fibers become irritated when the
bone is broken or bruised.

 Broken bones bleed, and the blood and associated swelling (edema) causes pain.

 Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments
in place, and these spasms cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It
is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover,
fractures don't always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces on the bone may determine
what type of injury that occurs. Descriptions of fractures can be confusing. They are based on:

 where in the bone the break has occurred,

 how the bone fragments are aligned, and

 whether any complications exist.

The first step in describing a fracture is whether it is open or closed. If the skin over the break is disrupted, then an
open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the
potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside
world, these injuries need to be cleaned out aggressively and many times require anesthesia in the operating room to
do the job effectively.

Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an
angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?
Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal
anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their
normal alignment.

What are common types of fractures?

Stress fracture

A stress fracture is an overuse injury. Because of repeated micro-trauma, the bone can fail to absorb the shock that
is being put upon it and become weakened. Most often it is seen in the lower leg, the shin bone (tibia), or foot.
Athletes are at risk the most, because they have repeated footfalls on hard surfaces. Tennis players, basketball
players, jumpers, and gymnasts are typically at risk. A March fracture is the name given to a stress fracture of the
metatarsal or long bones of the foot. (It is named because it often occurs in soldiers who are required to march long
distances.)

Diagnosis is made by history and physical exam, though on occasion a bone scan may be done to confirm the
diagnosis.

Treatment is conservative, rest, ice, and anti-inflammatory medication like ibuprofen. These fractures can take six to
eight weeks to heal (as long as the fracture can be seen on x-ray). Trying to return too quickly can cause re-injury,
and may also allow the stress fracture to extend through the entire bone.

Shin splints may have very similar symptoms as a stress fracture of the tibia but they are due to inflammation of the
lining of the bone, called the periosteum. Shin splints are caused by overuse, especially in runners, walkers, dancers,
including those who do aerobics. Muscles that run through the periosteum and the bone itself may also become
inflamed.

Treatment is similar to a stress fracture and physical therapy can be helpful.

Compression fracture

As people age, there is a potential for the bones to develop osteoporosis, a condition where bones lose their calcium
content. This makes bone more susceptible to breaking. One such type of injury is a compression fracture to the
spine, most often the thoracic or lumbar spine. Since we are an upright animal, if the bones of the back are weaker
than the force of gravity these bones can crumple. Pain is the major complaint, especially with movement.

Compression injuries of the back may or may not be associated with nerve or spinal cord injury. An x-ray of the back
can reveal the bone injury, however, sometimes a CT scan or MRI will be used to insure that no damage is done to
the spinal cord.

Treatment includes pain medication and often a back brace. Some compression fractures can also be treated with
vertebroplasty. Vertebroplasty involves inserting a glue-like material into the center of the collapsed spinal vertebra in
order to stabilize and strengthen the crushed bone. The glue (methylmethacrylate) is inserted with a needle and
syringe through anesthetized skin into the midportion of the vertebra under the guidance of specialized x-ray
equipment. Once inserted, the glue soon hardens, forming a cast-like structure with the locally broken bone.

Rib fracture

The ribs are especially vulnerable to injury and are prone to breaking due to a direct blow. Rib x-rays are rarely taken
as it doesn't matter if the rib is broken or just bruised. A chest x-ray is usually taken to make certain there is no
collapse or bruising of the lung.

When we breathe, it is like a bellows. We inhale air into our lungs and the ribs move out and the diaphragm moves
down. When a person has a rib injury, the pain associated with it makes breathing difficult, and the person has a
tendency to not take deep breaths. If the lung underlying the injury does not expand, it is at risk for infection. The
person is then susceptible to pneumonia (lung infection),which is characterized by fever, cough, and shortness of
breath.

As opposed to other parts of the body that can rest when they are injured, it is very important to take deep breaths to
prevent pneumonia when rib fractures are present. The treatment for bruised and broken ribs is the same: ice to the
chest wall, ibuprofen as an anti-inflammatory, deep breaths and pain medication. Even if all goes well, there will be
significant pain for four to six weeks.
With lower rib fractures, there may be concern about organs in the abdomen that the ribs protect. The liver is located
under the ribs on the right side of the chest, and the spleen under the ribs on the left side of the chest. Many times
your doctor may be more worried about abdominal injury than about the broken rib itself. Ultrasound or CT scan may
help diagnosis intra-abdominal injuries.

Skull fracture

With the wide availability of CT scans, skull x-rays are rarely taken to diagnose head injury. If a head injury exists, the
physician will feel or palpate the scalp and skull to determine if there may be a skull fracture. He will also look into the
ears to see if there is blood behind the ear drumm and he will also complete a neurologic examination.

The skull is a flat, compact bone and it takes significant force to break it. If a skull fracture exists, there is an
increased likelihood of bleeding in the brain, especially in children. There are guidelines that are available to decide
whether a CT scan is indicated (needed).

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in
patients with a GCS (Glasgow Coma Score) score of 13-15. With minor head injury, the following risk groups are
considered when evaluating need for CT brain scan:

High risk for potential neurosurgical operation

 Abnormal neurologic exam within two hours after injury

 Suspected open or depressed skull fracture

 Any sign of basal skull fracture (blood behind the ear drum, blackened eyes, clear fluid running from the
ears, or bruising behind the ear)

 Vomiting - two episodes

 65 years of age or older

Medium risk (for brain injury on CT)

 Amnesia before impact - more than 30 minutes

 Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from
height greater than 3 feet or five stairs)

Fracture in children

Children can break bones and yet have normal x-rays. Fractures appear as clear lines through the bone on an x-ray
through the bone. If calcium hasn't yet accumulated in the repairing bone, the break may not be apparent. This lack
of calcification happens in two ways.

1. Bones mature at different times in a child's development and while the bony structure is there, it may have
more cartilage than calcium.

2. The second situation is associated with growth plates. Each bone has an area where cell activity is maximal
and where the bone grows. These areas appear as lucent lines on x-ray. It may be one of the weaker points
in the bone as well, and a fracture through the growth plate may not be seen.

The doctor needs to match the history and physical exam with what is seen on x-ray to make to a diagnosis.
Sometimes, the child is placed in a cast for a period of time to protect the broken limb. As fractures heal, the body
lays down extra calcium as building material and then remodels it to normal shape. After 7-10 days, there may be
evidence on x-ray of the healing calcium to confirm the fracture.

Growth plate fractures are classified by Salter-Harris category. When a break occurs through the growth plate, it can
involve different parts of the bone on each side of the plate. It is important that these fractures are aligned properly so
that the bone grows properly as the child ages.

Children are more flexible than adults until the calcium completely solidifies their bone. If you think of an arm or leg
bone as tubular, sometimes only one side of the bone breaks, just like an immature branch on a tree. This is referred
to as a greenstick fracture, and may need to be "set" so that it heals properly. Sometimes the bones can bend but not
break because they are so pliable. This is called a plastic deformity and again will need to be set or aligned to allow
proper healing.

How is a fracture diagnosed?

When you arrive for medical care, the doctor will take a history of the injury. Where, when, and why did the injury
occur? Did the person trip and fall, or did they pass out before the fall? Are there other injuries that take precedence
over the fracture? For example, a person who falls and hurts their wrist because they had a stroke or heart attack will
have their fracture care delayed to allow care for the life threatening illness. The injured area will be examined and a
search will happen for potential associated injuries. These include damage to skin, arteries and nerves.

Pain control is a priority and many times, pain medication will be prescribed before the diagnosis is made. If the
doctor believes that an operation is likely, pain medication will be given through an intravenous (IV) line or by an
injection into the muscle. This allows the stomach to remain empty for potential anesthesia.

A decision will be made whether x-rays are required, and which type of x-ray should be taken to make the diagnosis
and better assess the injury. There are guidelines in place to help doctors decide if an x-ray is necessary. Some
include the Ottawa ankle and knee x-ray rules.

The body is three dimensional, and plain film x-rays are only two dimensional. Therefore, two or three x-rays of the
injured areas may be taken in different positions and planes to give a true picture of the injury. Sometimes the
fracture will not be seen in one position, but is easily seen in another.

There are areas of the body where one bone fracture is associated with another fracture at a more distant part. For
example, the bones of the forearm make a circle and it is difficult to break just one bone in that circle. Think of trying
to break a pretzel in just one place, it is difficult to do. Therefore broken bones at the wrist may be associated with an
elbow injury. Similarly, an ankle injury can be accompanied by a knee fracture. The doctor may x-ray areas of the
body that don't initially appear to be injured.

Occasionally, the broken bone isn't easily seen, but there may be other signs that a fracture exists. In elbow injuries,
fluid seen in the joint on x-ray is an indicator of a subtle fracture. And in wrist injuries, fractures of the scaphoid or
navicular bone may not show up on x-ray for one to two weeks, and diagnosis is made solely on physical
examination with swelling and tenderness over the snuffbox at the base of the thumb.

In children, bones may have numerous growth plates that can cause confusion when reading an x-ray. Sometimes,
the doctor will choose to x-ray the opposite arm or leg to determine what normal is for the child before deciding
whether a fracture exists.

What is the treatment of a fracture?

Initial treatment for fractures of the arms, legs, hands and feet in the field include splinting the extremity in the
position it is found, elevation and ice. Immobilization will be very helpful with initial pain control. For injuries of the
neck and back, many times, first responders or paramedics may choose to place the injured person on a long board
and in a neck collar to protect the spinal cord from potential injury.

Once the fracture has been diagnosed, the initial treatment for most limb fractures is a splint. Padded pieces of
plaster or fiberglass are placed over the injured limb and wrapped with gauze and an elastic wrap to immobilize the
break. The joints above and below the injury are immobilized to prevent movement at the fracture site. This initial
splint does not go completely around the limb. After a few days, the splint is removed and replaced by a
circumferential cast. Circumferential casting does not occur initially because fractures swell (edema). This swelling
would cause a build up of pressure under the cast, yielding increased pain and the potential for damage to the
tissues under the cast.

Surgery

Surgery on fractures are very much dependent on what bone is broken, where it is broken, and whether the
orthopedic surgeon believes that the break is at risk (for staying where it is) once the bone fragments have been
aligned. If the surgeon is concerned that the bones will heal improperly, an operation will be needed. Sometimes
bones that appear to be aligned normally are splinted, and at a recheck appointment, are found to be unstable and
require surgery.

Surgery can include closed reduction and casting, where under anesthesia, the bones are manipulated so that
alignment is restored and a cast is placed to hold the bones in that alignment. Sometimes, the bones are broken in
such a way that they need to have metal hardware inserted to hold them in place. Open reduction means that, in the
operating room, the skin is cut open and pins, plates, or rods are inserted into the bone to hold it in place until healing
occurs. Depending on the fracture, some of these pieces of metal are permanent (never removed), and some are
temporary until the healing of the bone is complete and surgically removed at a later time.

Bone fracture
Classification and external resources

Internal and external views of an arm with a compound fracture,

Sx2 (where x=0-9 depending on the location of

ICD-9 829

DiseasesDB 4939

MeSH D050723

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a break in the
continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of
certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, or osteogenesis imperfecta,
where the fracture is then properly termed a pathological fracture.

Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a formal
orthopedic term.

Classification

Orthopedic

In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first
described the fracture conditions. However, there are more systematic classifications in place currently.

All fractures can be broadly described as:

 Closed (simple) fractures are those in which the skin is intact, while 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.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is
large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These
injuries may take longer to heal than injuries without displacement or angulation.

Another type of bone fracture is a compression fracture. It 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).
Other types of fracture are:

 Complete fracture: A fracture in which bone fragments separate completely.

 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.

 Spiral fracture: A fracture where at least one part of the bone has been twisted.

 Comminuted fracture: A fracture in which the bone has broken into a number of pieces.

 Impacted fracture: A fracture caused when bone fragments are driven into each other.

OTA classification

The Orthopaedic Trauma Association, an association for orthopaedic surgeons, adopted and then extended the
classification of Müller and the AO foundation ("The Comprehensive Classification of the Long Bones") an elaborate
classification system to describe the injury accurately and guide treatment. There are five parts to the code:

 Bone: Description of a fracture starts by coding for the bone involved:}}

(1) Humerus, (2) Radius/Ulna, (3) Femur, (4) Tibia/Fibula, (5) Spine, (6) Pelvis, (24) Carpus, (25) Metacarpals, (26)
Phalanx (Hand), (72) Talus, (73) Calcaneus, (74) Navicular, (75) Cuneiform, (76) Cuboid, (80) LisFranc, (81)
Metatarsals, (82) Phalanx (Foot), (45) Patella, (06) Clavicle, (09) Scapula

 Location: a code for the part of the bone involved (e.g. shaft of the femur): proximal=1, diaphyseal=2,
distal=3 (at the ankle the malleolar region is considered separately due to the pre-existing Weber
classification and coded as 4). Except at the proximal femur the distal and proximal regions of the bone are
defined by a square that is as wide as the as the distance between the condyles. The diaphysis is
considered to be the rest of the bone between these two squares.
 Type: It is important to note whether the fracture is simple or multifragmentary and whether it is closed or
open: A=simple fracture, B=wedge fracture, C=complex fracture

 Group: The geometry of the fracture is also described by terms such as transverse, oblique, spiral, or
segmental.

 Subgroup: Other features of the fracture are described in terms of displacement, angulation and shortening.
A stable fracture is one which is likely to stay in a good (functional) position while it heals; an unstable one is
likely to shorten, angulate or rotate before healing and lead to poor function in the long term.

Other classification systems

There are other systems used to classify different types of bone fractures:

 "Denis classification": spine

 "Frykman classification": radius and ulna

 "Gustilo open fracture classification"

 "Letournel and Judet Classification": Acetabular Fractures

 "Neer classification": humerus

 "Seinsheimer's Classification": femur

Signs and symptoms

Although bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons:
  Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both
contain multiple nociceptors.

 Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain.

 Muscle spasms trying to hold bone fragments in place

Pathophysiology

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 remove 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 (calcium hydroxyapatite) 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 is on average
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 remodeling, the woven bone is
replaced by mature "lamellar" bone. The whole process can 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 can help or hinder the bone healing process. For example, any form of nicotine hinders the process
of bone healing, 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. The bone shards
can also embed in the muscle causing great pain. 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.

Diagnosis

A bone fracture can be diagnosed clinically, based on the history given and the physical examination performed by a
healthcare professional. Usually there will be an area of swelling, abrasion, bruising and/or tenderness at the
suspected fracture site.

Open fractures may be obvious if bone is exposed but small wounds may need surgical exploration to determine if
they are only superficial or connected to the fracture.

X-ray radiographs can be requested to view the bone suspected of being fractured.

In situations where x-ray alone is insufficient, a computed tomograph (CT scan) may be performed.

Treatment

X-ray showing the proximal portion of a fractured tibia with an intramedullary nail

.
 X-ray showing the distal portion of a fractured tibia and intramedular nail.

Pain management

In arm fractures in children, ibuprofen has been found to be equally effective as the combination of acetaminophen
and codeine

Immobilization

Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best
possible function of the injured part after healing. Bone fractures are typically 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 good position and verifying the improved alignment with an X-ray is all that is needed.
This process is extremely painful without anesthesia, about as painful as breaking the bone itself. To this end, a
fractured limb is usually immobilized with a plaster or fiberglass cast or splint which holds the bones in position and
immobilizes the joints above and below the fracture. When the initial post-fracture edema 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 method which is a form of 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. By allowing only limited movement, fixation helps
preserve anatomical alignment while enabling callus formation, towards the target of achieving union.

Surgery

Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if
conservative treatment has failed or is very likely to fail. With some fractures such as hip fractures (usually caused by
osteoporosis or osteogenesis Imperfecta), surgery is offered routinely, because the complications of non-operative
treatment include 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 their
limited blood flow. 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 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 easily accumulate 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.
Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results
however do not support its effectiveness.

Complications

An old fracture with nonunion of the fracture fragments.

Some fractures can lead to serious complications including a condition known as compartment syndrome. If not
treated, compartment syndrome can result in 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.

In children

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 as
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, is also 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 are known to occur mainly in the pediatric age group, such as fracture of the clavicle &
supracondylar fracture of the humerus.