COMMON FRACTURES

GENERAL PRINCIPLES OF FRACTURES

 

A fracture is a partial or complete interruption in the continuity of the 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.

 

FRACTURE CLASSIFICATION

Type Closed: Broken bone doesn’t break the skin
Open: Ends of broken bone tears the skin
Location Proximal: Fracture at the upper part of the bone
Distal: Fracture at the lower part of the bone
Position Diaphysis: Fracture at the mid-section of the bone
Metaphysis: Fracture at the growth plate of the bone
Epiphysis: Fracture at the rounded end of the long bone
Extent Complete: Bone gets crushed into two or more pieces
Incomplete: Bone cracks without breaking all the way through
Orientation Transverse: Fracture is at the right angle to the long plane of the bone
Oblique: Fracture is at an oblique angle to the long axis of the bone
Spiral: Fracture that occurs when a long bone is broken by a twisting force
Displacement Nondisplaced: Bone maintains its proper alignment
Displaced: The fracture segment does not maintain the bone alignment
Fragmentation Comminuted: Breaking of the bone into two or more fragments
Segmental: Fracture composed of at least two fracture lines, isolating a bone segment

OVERVIEW OF COMMON FRACTURES

 

Common fractures in children

Pediatric fractures often have distinct fracture patterns due to the unique properties of growing bones. 

The periosteum (outer covering of the bone) in growing bones is thicker and stronger than in adult bones, which is why children are more prone to more incomplete fractures, such as the greenstick fracture or torus fracture.

 In addition, the periosteum is metabolically active. This feature also explains why childhood fractures heal faster than fractures in adults. 

These fractures only arise in children and adolescents, whose skeletal growth is not yet complete. 

 

Common fractures in adults

Pathologic fracture

Osteoporosis is a skeletal condition in which the loss of bone mineral density leads to decreased bone strength and increased susceptibility to fractures. 

The disease typically affects postmenopausal women and the elderly. 

Further risk factors include inactivity, smoking, and alcohol consumption. 

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

Stress fractures are tiny cracks in a bone. They’re caused by repetitive force, often from overuse,  such as repeatedly jumping up and down or running long distances. Stress fractures can also develop from normal use of a bone that’s weakened by a condition such as osteoporosis

 

Colles fracture: distal radius 

Distal radius fractures are a common fracture of the arm, with a bimodal peak incidence between the second and third decade and individuals above 65 years of age. 

The mechanism of injury may be due to low-energy falls, especially in women with osteoporosis, or high-energy trauma that occurs during sports or motor vehicle accidents

Smith fracture: distal radius

It is caused by a direct blow to the dorsal forearm or falling onto flexed wrists, as opposed to a Colles’ fracture which occurs as a result of falling onto wrists in extension. Smith’s fractures are less common than Colles’ fractures.

The distal fracture fragment is displaced volarly (ventrally), as opposed to a Colles’ fracture which the fragment is displaced dorsally. Depending on the severity of the impact, there may be one or many fragments and it may or may not involve the articular surface of the wrist joint.

Scaphoid fracture

Fractures are most often localized in the middle third of the scaphoid bone. 

Generally, scaphoid bone fractures result from indirect trauma when an individual falls onto the outstretched hand with a hyperextended and radially deviated wrist. Pain when applying pressure to the anatomical snuffbox is highly suggestive of a scaphoid bone fracture. 

X-ray is the initial test of choice for diagnosis. 

Computer tomography and magnetic resonance imaging may be indicated, if x-ray findings are negative but clinical suspicion is high. 

Treatment can be conservative (e.g, wrist immobilization) or in certain cases surgical (e.g., proximal pole fracture). 

Complications include nonunion and avascular necrosis.              

Ankle fracture

Ankle fractures are the most common fractures of the lower extremity. 

They are most often caused by twisting the ankle, the circumstances of which the patient will typically recall. 

The major symptoms are pain in the affected area and decreased range of motion.

If physical examination and the patient history suggest a fracture (e.g., the patient is unable to bear weight on the affected leg), an x-ray is performed. 

The most important diagnostic consideration is whether the fracture is stable (as is the case in isolated malleolar fractures) or unstable (e.g., bimalleolar fracture). 

Unstable fractures require surgery, whereas stable fractures can be treated conservatively with a short leg cast.

Tibial fracture

Tibial fractures are the most common type of long bone fractures. They are usually caused by direct trauma and may occur proximally (tibial plateau fracture), at the shaft, or distally. The fracture may solely involve the tibia or the fibula, or it may involve both. 

As only a small amount of tissue covers the bone structures, there is a higher risk of open fracture, neurovascular injury, compartment syndrome, and wound infection. 

Depending on the location and stability of the fracture, treatment may involve casting, intramedullary nailing, open reduction and internal fixation, or external fixation