Bone fracture

An old fracture with nonunion of the fracture fragments

Some fractures may lead to serious complications including a condition known as compartment syndrome. If not treated, eventually, compartment syndrome may 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. One form of malunion is the malrotation of a bone, which is especially common after femoral and tibial fractures.[5] Complications of fractures may 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.

Smokers generally have lower bone density than non-smokers, so they have a much higher risk of fractures. There is also evidence that smoking delays bone healing.[9]

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 physician who first described the fracture conditions, however, there are more systematic classifications as well.

They may be divided into stable versus unstable depending on the likelihood that they may shift further.

• Traumatic fracture – 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 that 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

• Closed/simple fractures are those in which the overlying skin is intact[10]
• 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. Reports indicate an incidence of infection after internal fixation of closed fracture of 1-2%, rising to 30% in open fractures.[11]
  • Clean fracture
  • Contaminated fracture

• Non-displaced
• Displaced
  • Translated, or ad latus, with sideways displacement.[12]
  • Angulated
  • Rotated
  • Shortened, a reduction in overall bone length when displaced fracture fragments overlap

• 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

• 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.

An anatomical classification may begin with specifying the involved body part, such as the head or arm, followed by more specific localization. Fractures that have additional definition criteria than merely localization often may be classified as subtypes of fractures, such as a Holstein-Lewis fracture being a subtype of a humerus fracture. Most typical examples in an orthopaedic classification given in the previous section cannot be classified appropriately into any specific part of an anatomical classification, however, as they may apply to multiple anatomical fracture sites.

• Skull fracture
  • Basilar skull fracture
  • Blowout fracture – a fracture of the walls or floor of the orbit
  • Mandibular fracture
  • Nasal fracture
  • Le Fort fracture of skull – facial fractures involving the maxillary bone and surrounding structures in a usually bilateral and either horizontal, pyramidal, or transverse way.
• Spinal fracture
  • Cervical fracture
    • Fracture of C1, including Jefferson fracture
    • Fracture of C2, including Hangman's fracture
    • Flexion teardrop fracture – a fracture of the anteroinferior aspect of a cervical vertebral
  • Clay-shoveler fracture – fracture through the spinous process of a vertebra occurring at any of the lower cervical or upper thoracic vertebrae
  • Burst fracture – in which a vertebra breaks from a high-energy axial load
  • Compression fracture – a collapse of a vertebra, often in the form of wedge fractures due to larger compression anteriorly
  • Chance fracture – compression injury to the anterior portion of a vertebral body with concomitant distraction injury to posterior elements
  • Holdsworth fracture – an unstable fracture dislocation of the thoraco lumbar junction of the spine
• Rib fracture
• Sternal fracture
• Shoulder fracture
  • Clavicle fracture
  • Scapular fracture
• Arm fracture
  • Humerus fracture (fracture of upper arm)
    • Supracondylar fracture
    • Holstein-Lewis fracture – a fracture of the distal third of the humerus resulting in entrapment of the radial nerve
  • Forearm fracture
    • Ulnar fracture
      • Monteggia fracture – a fracture of the proximal third of the ulna with the dislocation of the head of the radius
      • Hume fracture – a fracture of the olecranon with an associated anterior dislocation of the radial head
    • Radius fracture
      • Essex-Lopresti fracture – a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint with disruption of the interosseous membrane[13]
      • Distal radius fracture
        • Galeazzi fracture – a fracture of the radius with dislocation of the distal radioulnar joint
        • Colles' fracture – a distal fracture of the radius with dorsal (posterior) displacement of the wrist and hand
        • Smith's fracture – a distal fracture of the radius with volar (ventral) displacement of the wrist and hand
        • Barton's fracture – an intra-articular fracture of the distal radius with dislocation of the radiocarpal joint
• Hand fracture
  • Scaphoid fracture
  • Rolando fracture – a comminuted intra-articular fracture through the base of the first metacarpal bone
  • Bennett's fracture – a fracture of the base of the first metacarpal bone which extends into the carpometacarpal (CMC) joint [14]
  • Boxer's fracture – a fracture at the neck of a metacarpal
• Broken finger – a fracture of the carpal phalanges
• Pelvic fracture
  • Fracture of the hip bone
  • Duverney fracture – an isolated pelvic fracture involving only the iliac wing
• Femoral fracture
  • Hip fracture (anatomically a fracture of the femur bone and not the hip bone)
• Patella fracture
• Crus fracture
  • Tibia fracture
    • Pilon fracture
    • Tibial plateau fracture
    • Bumper fracture – a fracture of the lateral tibial plateau caused by a forced valgus applied to the knee
    • Segond fracture – an avulsion fracture of the lateral tibial condyle
    • Gosselin fracture – a fractures of the tibial plafond into anterior and posterior fragments [15]
    • Toddler's fracture – an undisplaced and spiral fracture of the distal third to distal half of the tibia [16]
  • 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
    • Le Fort fracture of ankle – a vertical fracture of the antero-medial part of the distal fibula with avulsion of the anterior tibiofibular ligament[15]
    • Bosworth fracture – a fracture with an associated fixed posterior dislocation of the distal fibular fragment that becomes trapped behind the posterior tibial tubercle; the injury is caused by severe external rotation of the ankle [17]
  • Combined tibia and fibula fracture
    • Trimalleolar fracture – involving the lateral malleolus, medial malleolus, and the distal posterior aspect of the tibia
    • Bimalleolar fracture – involving the lateral malleolus and the medial malleolus
    • Pott's fracture
• Foot fracture
  • Lisfranc fracture – in which one or all of the metatarsals are displaced from the tarsus[18]
  • Jones fracture – a fracture of the proximal end of the fifth metatarsal
  • March fracture – a fracture of the distal third of one of the metatarsals occurring because of recurrent stress
  • Cuneiform fracture – a fracture of one of the three cuneiform bones typically due to direct blow, axial load, or avulsion [19]
  • Calcaneal fracture – a fracture of the calcaneus (heel bone)
• Broken toe – a fracture of the pedal phalanges

The Orthopaedic Trauma Association Committee for Coding and Classification published its classification system [20] in 1996, adopting a similar system to the 1987 AO Foundation system.[21] In 2007, they extended their system,[22] unifying the two systems regarding wrist, hand, foot, and ankle fractures.

A number of classifications are named after the person (eponymous) who developed it.

• "Denis classification" for spinal fractures [23]
• "Frykman classification" for forearm fractures (fractures of radius and ulna)
• "Gustilo open fracture classification" [24]
• "Letournel and Judet Classification" for Acetabular fractures [25]
• "Neer classification" for humerus fractures [26][27]
• Seinsheimer classification, Evans-Jensen classification, Pipkin classification, and Garden classification for hip fractures[28]

In arm fractures in children, ibuprofen has been found to be as effective as a combination of paracetamol and codeine.[36] In the ems setting it might be applicable to administer 1mg/kg of iv ketamine to achieve a dissociated state.

Since bone healing is a natural process that will occur most often, fracture treatment aims to ensure the best possible function of the injured part after healing. Bone fractures typically are 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 a good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful without anaesthesia, about as painful as breaking the bone itself. To this end, a fractured limb usually is immobilized with a plaster or fibreglass cast or splint that holds the bones in position and immobilizes the joints above and below the fracture. When the initial post-fracture oedema 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 an 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. A device called a Suzuki frame may be used in cases of deep, complex intra-articular digit fractures.[37] By allowing only limited movement, immobilization helps preserve anatomical alignment while enabling callus formation, toward the target of achieving union.

Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting.[38]

Surgical methods of treating fractures have their own risks and benefits, but usually, surgery is performed only if conservative treatment has failed, is very likely to fail, or is likely to result in a poor functional outcome.[39] 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.[40] 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 use of antibiotics.

Occasionally, bone grafting is used to treat a fracture.[41]

Sometimes bones are reinforced with metal.[42] 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 accumulate easily 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.

A Cochrane review of low-intensity pulsed ultrasound to speed healing in newly broken bones found insufficient evidence to justify routine use.[43] Other reviews have found tentative evidence of benefit.[44] It may be an alternative to surgery for established nonunions.[45]