Bone fracture: Difference between revisions

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A '''bone fracture''' (sometimes abbreviated '''FRX''' or '''Fx''', '''F<sub>x</sub>''', or '''#''') is a medical condition in which there is a damage in the continuity of the [[bone]]. A bone fracture can be the result of high force [[Impact force|impact]] or [[Stress fracture|stress]], or a minimal trauma 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 [[pathologic fracture]].<ref>{{cite book |author1=Marshall, S.T. |author2=Browner, B.D. |lastauthoramp=yes |editor= Townsend, Courtney M. Jr. |title= Sabiston textbook of surgery: the biological basis of modern surgical practice |publisher= Elsevier |year=2012 |origyear=1st. Pub. 1956 |pages=480–520 |chapter=Chapter 20: Emergency care of musculoskeletal injuries |chapterurl= |isbn=978-1-4377-1560-6}}</ref>
A '''bone fracture''' (sometimes abbreviated '''FRX''' or '''Fx''', '''F<sub>x</sub>''', or '''#''') is a medical condition in which there is a damage in the continuity of the [[bone]]. A bone fracture can be the result of high force [[Impact force|impact]] or [[Stress fracture|stress]], or a minimal trauma 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 [[pathologic fracture]].<ref>{{cite book |first1=Daniel K. |last1=Witmer |first2=Silas T. |last2=Marshall |first3=Bruce D. |last3=Browner |chapter=Emergency Care of Musculoskeletal Injuries |chapterurl={{Google books|KYstDAAAQBAJ|page=462|plainurl=yes}} |pages=462–504 |editor1-first=Courtney M. |editor1-last=Townsend |editor2-first=R. Daniel |editor2-last=Beauchamp |editor3-first=B. Mark |editor3-last=Evers |editor4-first=Kenneth L. |editor4-last=Mattox |year=2016 |title=Sabiston Textbook of Surgery |edition=20th |publisher=Elsevier |isbn=978-0-323-40163-0 }}</ref>


Although '''broken bone''' and '''bone break''' are common colloquialisms for a bone fracture, ''break'' is not a formal [[Orthopedic surgery|orthopedic]] term.
Although '''broken bone''' and '''bone break''' are common colloquialisms for a bone fracture, ''break'' is not a formal [[Orthopedic surgery|orthopedic]] term.
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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 [[crystal]]s. 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 [[Fibrocartilage callus|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.
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 [[crystal]]s. 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 [[Fibrocartilage callus|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,<ref name="pmid20303894">{{cite journal |vauthors=Sloan A, Hussain I, Maqsood M, Eremin O, El-Sheemy M |title=The effects of smoking on fracture healing |journal=Surgeon |volume=8 |issue=2 |pages=111–6 |year=2010 |pmid=20303894 |doi=10.1016/j.surge.2009.10.014 |url=}}</ref> 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.
Several factors can help or hinder the [[bone healing]] process. For example, any form of [[nicotine]] hinders the process of bone healing,<ref name="pmid20303894">{{cite journal |doi=10.1016/j.surge.2009.10.014 }}</ref> 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.<ref>{{cite web |url=http://www.bestbets.org/bets/bet.php?id=162|work=bestbets.org |title=BestBets: Do non-steroidal anti-inflammatory drugs cause a delay in fracture healing? }}</ref>
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.<ref>{{cite journal |doi=10.1100/2012/606404 }}</ref>


===Effects of smoking===
===Effects of smoking===
Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There is also evidence that smoking delays bone healing. Some research indicates, for example, that it delays tibial shaft fracture healing from a median healing time of 136 to 269 days.<ref>{{cite web|url=http://www.medicine.ox.ac.uk/bandolier/booth/painpag/wisdom/NSAIbone.html |title=Do NSAIDs inhibit bone healing? |publisher=Medicine.ox.ac.uk |accessdate=2011-12-25}}</ref> This means that the fracture healing time was approximately doubled in smokers. Although some other studies show less extreme effects, it is still shown that smoking delays fracture healing.
Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There is also evidence that smoking delays bone healing.<ref>{{cite journal |doi=10.1007/s00198-004-1640-3 }}</ref>


==Diagnosis==
==Diagnosis==
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***[[Segond fracture]] – an [[avulsion fracture]] of the [[Tibia|lateral tibial condyle]]
***[[Segond fracture]] – an [[avulsion fracture]] of the [[Tibia|lateral tibial condyle]]
***[[Gosselin fracture]] – a fractures of the tibial [[synovial joint|plafond]] into anterior and posterior fragments<ref name="hunter"/>
***[[Gosselin fracture]] – a fractures of the tibial [[synovial joint|plafond]] into anterior and posterior fragments<ref name="hunter"/>
***[[Toddler's fracture]] – an undisplaced and spiral fracture of the distal third to distal half of the tibia<ref name="pmid10532655">{{cite journal |vauthors=Mellick LB, Milker L, Egsieker E |title=Childhood accidental spiral tibial (CAST) fractures |journal=Pediatr Emerg Care |volume=15 |issue=5 |pages=307–9 |date=October 1999 |pmid=10532655 |doi= 10.1097/00006565-199910000-00001|url=}}</ref>
***[[Toddler's fracture]] – an undisplaced and spiral fracture of the distal third to distal half of the tibia<ref name="pmid10532655">{{cite journal |doi=10.1097/00006565-199910000-00001 }}</ref>
**[[Fibular fracture]]
**[[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.
***[[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 [[Anterior and posterior|antero]]-[[Human anatomical terms#Front and back|medial]] part of the [[Anatomical terms of location#Proximal and distal|distal]] [[fibula]] with [[Avulsion fracture|avulsion]] of the [[anterior ligament of the lateral malleolus|anterior tibiofibular ligament]].<ref name="hunter">{{cite journal |author1=Tim B Hunter |author2=Leonard F Peltier |author3=Pamela J Lund |year=2000 |title=Musculoskeletal Eponyms: Who Are Those Guys? |journal=RadioGraphics |volume=20 |issue=3 |pages=819–36 |url=http://radiographics.rsna.org/content/20/3/819.full.pdf |accessdate=2009-11-13 |doi=10.1148/radiographics.20.3.g00ma20819 |pmid=10835130}}</ref>
***[[Le Fort fracture of ankle]] – a vertical fracture of the [[Anterior and posterior|antero]]-[[Human anatomical terms#Front and back|medial]] part of the [[Anatomical terms of location#Proximal and distal|distal]] [[fibula]] with [[Avulsion fracture|avulsion]] of the [[anterior ligament of the lateral malleolus|anterior tibiofibular ligament]].<ref name="hunter">{{cite journal |doi=10.1148/radiographics.20.3.g00ma20819 }}</ref>
***[[Bosworth fracture]] – a fracture with an associated fixed [[Anterior and posterior|posterior]] [[Joint dislocation|dislocation]] of the proximal fibular fragment which becomes trapped behind the [[Tibia|posterior tibial tubercle]]. The injury is caused by severe [[external rotation]] of the ankle.<ref name="perry">{{cite journal |last=Perry|first=CR |author2=Rice S |author3=Rao A |author4=Burdge R. |date=Oct 1983 |title=Posterior fracture-dislocation of the distal part of the fibula. Mechanism and staging of injury |journal=J Bone Joint Surg Am.|volume=65 |issue=8 |pages=1149–57 |pmid=6630259|url=http://www.ejbjs.org/cgi/reprint/65/8/1149 |accessdate=2009-10-10}}</ref>
***[[Bosworth fracture]] – a fracture with an associated fixed [[Anterior and posterior|posterior]] [[Joint dislocation|dislocation]] of the proximal fibular fragment which becomes trapped behind the [[Tibia|posterior tibial tubercle]]. The injury is caused by severe [[external rotation]] of the ankle.<ref name="perry">{{cite journal |pmid=6630259 |url=http://www.jbjs.org/cgi/pmidlookup?view=long&pmid=6630259 }}</ref>
**[[Combined tibia and fibula fracture]]
**[[Combined tibia and fibula fracture]]
***[[Trimalleolar fracture]] – involving the [[lateral malleolus]], [[medial malleolus]] and the distal posterior aspect of the tibia
***[[Trimalleolar fracture]] – involving the [[lateral malleolus]], [[medial malleolus]] and the distal posterior aspect of the tibia
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{{main article|Müller AO Classification of fractures}}
{{main article|Müller AO Classification of fractures}}


The [[Orthopaedic Trauma Association]] Committee for Coding and Classification published its classification system<ref>{{cite journal | title=Fracture and dislocation compendium | author=Orthopaedic Trauma Association Committee for Coding and Classification | journal=J Orthop Trauma | year=1996 | volume=10 | issue=Suppl 1:v–ix | pages=1–154 | pmid=8814583}}</ref> in 1996, adopting a similar system to the 1987 [[AO Foundation]] system.<ref>{{cite book | title=Classification AO des fractures. Tome I. Les os longs | publisher=Springer-Verlag |vauthors=Müller ME, Nazarian S, Koch P | year=1987 | location=Berlin}}</ref> In 2007, they extended their system,<ref>{{cite journal | title=Fracture and Dislocation Classification | author=Orthopaedic Trauma Association | journal=J Orthop Trauma | year=2007 | volume=21 | issue=Suppl | pages=S1–S133 | pmid=18277234}}</ref> unifying the 2 systems regarding wrist, hand, foot and ankle fractures.
The [[Orthopaedic Trauma Association]] Committee for Coding and Classification published its classification system<ref>{{cite journal |pmid=8814583 }}</ref> in 1996, adopting a similar system to the 1987 [[AO Foundation]] system.<ref>{{cite book | title=Classification AO des fractures. Tome I. Les os longs | publisher=Springer-Verlag |vauthors=Müller ME, Nazarian S, Koch P | year=1987 | location=Berlin}}{{pn}}</ref> In 2007, they extended their system,<ref>{{cite journal |pmid=18277234 }}</ref> unifying the 2 systems regarding wrist, hand, foot and ankle fractures.


===Classifications named after people===
===Classifications named after people===
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* "[[Frykman classification]]" for [[forearm fracture]]s (fractures of [[radius and ulna]])
* "[[Frykman classification]]" for [[forearm fracture]]s (fractures of [[radius and ulna]])
* "[[Gustilo open fracture classification]]"<ref Name="Rüedi">{{cite book
* "[[Gustilo open fracture classification]]"<ref Name="Rüedi">{{cite book
|title= AO principles of fracture management, Volume 1|last= Rüedi, etc. all|first= |authorlink= |author2=Thomas P. Rüedi |author3=Richard E. Buckley |author4=Christopher G. Moran |year= 2007|publisher= Thieme|location= |isbn= 3-13-117442-0|page= Page 96|pages= |url=https://books.google.com/?id=WEzRr4bM05gC&pg=PA96&dq=Gustilo+open+fracture+classification&q=Gustilo%20open%20fracture%20classification }}</ref>
|title= AO principles of fracture management, Volume 1|last= Rüedi, etc. all|first= |authorlink= |author2=Thomas P. Rüedi |author3=Richard E. Buckley |author4=Christopher G. Moran |year= 2007|publisher= Thieme|location= |isbn= 3-13-117442-0|page=96 |url=https://books.google.com/?id=WEzRr4bM05gC&pg=PA96&dq=Gustilo+open+fracture+classification&q=Gustilo%20open%20fracture%20classification }}</ref>
* "Letournel and Judet Classification" for [[Acetabular fracture]]s<ref name="Fractures of the Acetabulum">{{cite web|url=http://www.wheelessonline.com/ortho/fractures_of_the_acetabulum|title=Fractures of the Acetabulum|work=wheelessonline.com}}</ref>
* "Letournel and Judet Classification" for [[Acetabular fracture]]s<ref name="Fractures of the Acetabulum">{{cite web|url=http://www.wheelessonline.com/ortho/fractures_of_the_acetabulum|title=Fractures of the Acetabulum|work=wheelessonline.com}}</ref>
* "Neer classification" for [[humerus fracture]]s<ref name="pmid9155417">{{cite journal |author=Mourad L |title=Neer classification of fractures of the proximal humerus |journal=Orthop Nurs |volume=16 |issue=2 |page=76 |year=1997 |pmid=9155417|doi=}}</ref><ref name="titleeMedicine - Proximal Humerus Fractures: Article by Mark Frankle, MD">{{cite web|url=http://www.emedicine.com/orthoped/topic271.htm |title=eMedicine – Proximal Humerus Fractures: Article by Mark Frankle, MD|accessdate=2007-12-15 |work=}}</ref>
* "Neer classification" for [[humerus fracture]]s<ref name="pmid9155417">{{cite journal |pmid=9155417 }}</ref><ref name="titleeMedicine - Proximal Humerus Fractures: Article by Mark Frankle, MD">{{EMedicine|article|1261320|Proximal Humerus Fractures}}</ref>
* [[Seinsheimer classification]], [[Evans-Jensen classification]], [[Pipkin classification]] and [[Garden classification]] for [[hip fracture]]s
* [[Seinsheimer classification]], [[Evans-Jensen classification]], [[Pipkin classification]] and [[Garden classification]] for [[hip fracture]]s


Line 183: Line 183:


===Pain management===
===Pain management===
In arm fractures in children, [[ibuprofen]] has been found to be as effective as a combination of [[acetaminophen]] and [[codeine]].<ref>{{cite journal |vauthors=Drendel AL, Gorelick MH, Weisman SJ, Lyon R, Brousseau DC, Kim MK |title=A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain |journal=Ann Emerg Med |volume=54 |issue=4 |pages=553–60 |date=October 2009 |pmid=19692147 |doi=10.1016/j.annemergmed.2009.06.005 |url=}}</ref>
In arm fractures in children, [[ibuprofen]] has been found to be as effective as a combination of [[acetaminophen]] and [[codeine]].<ref>{{cite journal |doi=10.1016/j.annemergmed.2009.06.005 }}</ref>


===Immobilization===
===Immobilization===
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Occasionally smaller bones, such as phalanges of the [[toes]] and [[finger]]s, 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 [[Fibrocartilage callus|callus]] formation, towards the target of achieving union.
Occasionally smaller bones, such as phalanges of the [[toes]] and [[finger]]s, 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 [[Fibrocartilage callus|callus]] formation, towards the target of achieving union.


Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.<ref>{{cite journal |vauthors=Boutis K, Willan A, Babyn P, Goeree R, Howard A |title=Cast versus splint in children with minimally angulated fractures of the distal radius: a randomized controlled trial |journal=CMAJ |volume=182 |issue=14 |pages=1507–12 |date=October 2010 |pmid=20823169 |pmc=2950182 |doi=10.1503/cmaj.100119 |url=}}</ref>
Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.<ref>{{cite journal |doi=10.1503/cmaj.100119 }}</ref>


===Surgery===
===Surgery===
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Sometimes bones are reinforced with metal. These [[implant (medicine)|implant]]s 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-[[Young's modulus|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 [[ion]]s produced can damage the [[bone]] locally and may cause systemic effects as well.
Sometimes bones are reinforced with metal. These [[implant (medicine)|implant]]s 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-[[Young's modulus|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 [[ion]]s produced can damage the [[bone]] locally and may cause systemic effects as well.


In some cases, a low intensity pulsed ultrasound (LIPUS) bone stimulator can be used to accelerate bone healing. <ref>https://www.ncbi.nlm.nih.gov/pubmed/9234872</ref> The LIPUS bone stimulator known as EXOGEN is approved by the FDA to accelerate the healing of certain types of fractures.<ref>http://exogen.com/us/physicians/indications-and-effectiveness</ref> The device delivers painless ultrasonic or pulsed electromagnetic waves to a bone to stimulate healing. The stimulator is placed over the skin near the fracture for between 20 minutes and several hours each day. The stimulator must be used every day to be effective.
In some cases, a low intensity pulsed ultrasound (LIPUS) bone stimulator can be used to accelerate bone healing.<ref>{{cite journal |pmid=9234872 |url=http://www.jbjs.org/cgi/pmidlookup?view=long&pmid=9234872 }}</ref> The LIPUS bone stimulator known as EXOGEN is approved by the FDA to accelerate the healing of certain types of fractures.<ref>http://exogen.com/us/physicians/indications-and-effectiveness{{full}}</ref> The device delivers painless ultrasonic or pulsed electromagnetic waves to a bone to stimulate healing. The stimulator is placed over the skin near the fracture for between 20 minutes and several hours each day. The stimulator must be used every day to be effective.


[[Electrotherapy#Electrical bone growth stimulation|Electrical bone growth stimulation]] or [[osteostimulation]] has been attempted to speed or improve bone healing. Results however do not support its effectiveness.<ref>{{cite journal |vauthors=Mollon B, da Silva V, Busse JW, Einhorn TA, Bhandari M |title=Electrical stimulation for long-bone fracture-healing: a meta-analysis of randomized controlled trials |journal=J Bone Joint Surg Am |volume=90 |issue=11 |pages=2322–30 |date=November 2008 |pmid=18978400 |doi=10.2106/JBJS.H.00111 |url=}}</ref>
[[Electrotherapy#Electrical bone growth stimulation|Electrical bone growth stimulation]] or [[osteostimulation]] has been attempted to speed or improve bone healing. Results however do not support its effectiveness.<ref>{{cite journal |doi=10.2106/JBJS.H.00111 }}</ref>


===Complications===
===Complications===

Revision as of 23:37, 4 December 2016

"Broken bones" redirects here. For other uses, see Broken Bones.
Bone fracture
SpecialtyOsteology Edit this on Wikidata

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a damage in the continuity of the bone. A bone fracture can 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, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.[1]

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

Signs and symptoms

Although bone tissue itself contains no nociceptors, bone fracture is painful for several reasons:[2]

  • Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple pain receptors.
  • 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. Sometimes also followed by cramping.

Damage to adjacent structures such as nerves or vessels, spinal cord and nerve roots (for spine fractures), or cranial contents (for skull fractures) can cause other specific signs and symptoms.

Pathophysiology

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 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 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 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,[3] 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.[4]

Effects of smoking

Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There is also evidence that smoking delays bone healing.[5]

Diagnosis

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 is often 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

"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 doctor who first described the fracture conditions. However, there are more systematic classifications in place currently.

Mechanism

  • 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 which 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 – A fracture at the point of mechanical weakness at the end of an implant

Soft-tissue involvement

  • Closed fracture: are those in which the overlying skin is intact
  • Open fracture/Compound fracture: 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.
    • Clean fracture
    • Contaminated fracture

Displacement

  • Non-displaced
  • Displaced
    • Translated
    • Angulated
    • Rotated
    • Shortened

Fracture pattern

  • 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

  • Incomplete fracture: 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: A fracture in which bone fragments separate completely.
  • Comminuted fracture: A fracture in which the bone has broken into several pieces.

Anatomical location

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 can often be classified as subtypes of fractures that merely are, such as a Holstein-Lewis fracture being a subtype of a humerus fracture. However, most typical examples in an orthopedic classification given in previous section cannot appropriately be classified into any specific part of an anatomical classification, as they may apply to multiple anatomical fracture sites.

OTA/AO classification

Main article: Müller AO Classification of fractures

The Orthopaedic Trauma Association Committee for Coding and Classification published its classification system[12] in 1996, adopting a similar system to the 1987 AO Foundation system.[13] In 2007, they extended their system,[14] unifying the 2 systems regarding wrist, hand, foot and ankle fractures.

Classifications named after people

Main category: Orthopedic classifications

Treatment

X-ray showing the proximal portion of a fractured tibia with an intramedullary nail.
Proximal femur nail with locking and stabilisation screws for treatment of femur fractures of left thigh.
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.

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 surgically opened, regardless of whether the fracture itself is an open or closed fracture.

Pain management

In arm fractures in children, ibuprofen has been found to be as effective as a combination of acetaminophen and codeine.[20]

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.

Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.[21]

Surgery

Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done 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 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.

In some cases, a low intensity pulsed ultrasound (LIPUS) bone stimulator can be used to accelerate bone healing.[22] The LIPUS bone stimulator known as EXOGEN is approved by the FDA to accelerate the healing of certain types of fractures.[23] The device delivers painless ultrasonic or pulsed electromagnetic waves to a bone to stimulate healing. The stimulator is placed over the skin near the fracture for between 20 minutes and several hours each day. The stimulator must be used every day to be effective.

Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results however do not support its effectiveness.[24]

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 eventually 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.

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

Children

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 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.

See also

References

  1. ^ Witmer, Daniel K.; Marshall, Silas T.; Browner, Bruce D. (2016). "Emergency Care of Musculoskeletal Injuries". In Townsend, Courtney M.; Beauchamp, R. Daniel; Evers, B. Mark; Mattox, Kenneth L. (eds.). Sabiston Textbook of Surgery (20th ed.). Elsevier. pp. 462–504. ISBN 978-0-323-40163-0. {{cite book}}: External link in |chapterurl= (help); Unknown parameter |chapterurl= ignored (|chapter-url= suggested) (help)
  2. ^ MedicineNet – Fracture Medical Author: Benjamin C. Wedro, MD, FAAEM.
  3. ^ . doi:10.1016/j.surge.2009.10.014. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  4. ^ . doi:10.1100/2012/606404. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)CS1 maint: unflagged free DOI (link)
  5. ^ . doi:10.1007/s00198-004-1640-3. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  6. ^ Essex Lopresti fracture at Wheeless' Textbook of Orthopaedics online
  7. ^ "Bennett's fracture-subluxation". GPnotebook.
  8. ^ a b . doi:10.1148/radiographics.20.3.g00ma20819. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  9. ^ . doi:10.1097/00006565-199910000-00001. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  10. ^ . PMID 6630259 http://www.jbjs.org/cgi/pmidlookup?view=long&pmid=6630259. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  11. ^ TheFreeDictionary > Lisfranc's fracture Citing: Mosby's Medical Dictionary, 8th edition. Copyright 2009
  12. ^ . PMID 8814583. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  13. ^ Müller ME, Nazarian S, Koch P (1987). Classification AO des fractures. Tome I. Les os longs. Berlin: Springer-Verlag.[page needed]
  14. ^ . PMID 18277234. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  15. ^ "Denis classification of spinal fractures". GPnotebook.
  16. ^ Rüedi, etc. all; Thomas P. Rüedi; Richard E. Buckley; Christopher G. Moran (2007). AO principles of fracture management, Volume 1. Thieme. p. 96. ISBN 3-13-117442-0.
  17. ^ "Fractures of the Acetabulum". wheelessonline.com.
  18. ^ . PMID 9155417. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  19. ^ Proximal Humerus Fractures at eMedicine
  20. ^ . doi:10.1016/j.annemergmed.2009.06.005. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  21. ^ . doi:10.1503/cmaj.100119. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  22. ^ . PMID 9234872 http://www.jbjs.org/cgi/pmidlookup?view=long&pmid=9234872. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)
  23. ^ http://exogen.com/us/physicians/indications-and-effectiveness[full citation needed]
  24. ^ . doi:10.2106/JBJS.H.00111. {{cite journal}}: Cite journal requires |journal= (help); Missing or empty |title= (help)

External links

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