Fractures (Broken Bone)

What is a Fracture?

A fracture is a break in a bone, often from a high impact injury. Fractures are a common bone injury, and have many associated causes and risk factors. Fractures are usually acute- resulting from an incident such as a fall or motor vehicle accident. They are often diagnosed via x-rays. Fractures can also occur from repetitive loading of a bone leading to a stress fracture. Risk factors for fractures includes any condition that leads to weakening of the bone such as osteoporosis. A fracture may present as a complete break with loss of continuity of the bone. However, a fracture can also resemble a “crack” (hairline fracture) that is a subtle finding on regular x-rays and in some instances will require a CT scan or MRI to make a definitive diagnosis.

Types of Fractures

Fractures can be described based on the extent of injury, as well as the pattern of injury.

Extent of Injury

• Closed: a fracture that leaves the skin unbroken.
• Open (Compound): a fracture that breaks through the skin and surrounding tissue, thereby increasing the risk of wound infection and bone infection (osteomyelitis).
• Partial (Incomplete): a fracture that does not completely separates the bone into two fragments.
• Complete: a complete discontinuity of the bone that results in 2 or more distinct pieces.
• Stress: A stress fracture is an overuse injury, and presents as small cracks in the bone that are usually only visible using imaging techniques such as X-ray or MRI.

Pattern of Injury -Types of Fractures (Figure 1)

• Avulsion: An avulsion fracture occurs when a tendon or ligament pulls on the bone causing the tendon to pull off (avulse) a fragment of bone that it attaches to.
• Comminuted: A complete fracture is a fracture with two or more bone pieces or fragments present at the site of the fracture.
• Compression: A compression fracture occurs when the bone is crushed and therefore looks flatter. A compression fracture is commonly seen in the spine, commonly in patients with weakened bone from osteoporosis .
• Greenstick: A greenstick fracture is an incomplete fracture that most commonly occurs in children when the bones are softer and the tissues surrounding the bone (periosteum) is stronger. A greenstick fracture occurs when the soft bone bends and one side breaks, but the crack does not extend across the entire bone often because the strong periosteum keeps the bone partially intact.
• Impacted: In an impacted fracture, the broken bones are driven into (impacted) each other. 
• Oblique: An oblique fracture is a complete fracture in which the break pattern is slanted or diagonal.
• Spiral: A spiral fracture is a complete fracture that occur when a twisting or rotating force is applied to the on the bone. Bones tend to be strong when a bending or compression force is applied, but they are weaker when a twisting (rotational) force is applied. 
• Transverse: A transverse fracture is a complete fracture in which the break pattern is a straight “transverse” line across.

Clinical Presentation

Patient presentation will vary depending on the type and extent of the fracture. Patients will commonly present with marked pain and difficulty utilizing the injured area. Bruising to the affected region is common. Patients will usually have a history a recent traumatic event. For patients with chronic disease-related fractures, the patient may have a history of osteoporosis or other conditions affecting the density of the bones (ex. corticosteroid use).

Physical Examination

Fractures are typically very painful right where the fracture has occurred. A displaced fracture will often have an associated deformity of the affected extremity. Patients who have suffered a fracture will usually be unable to, or have great difficulty, using the area around the broken bone. If the fracture involves the lower limbs (legs), this will manifest as difficulty or inability to bear weight. Patients with an open fracture will have a region of broken skin that usually bleeds where the bone penetrated the skin. Open fractures are more severe than closed fractures because of the increased risk of infection. Patients with an open fracture should visit an emergency room and receive urgent treatment.

Imaging

A diagnosis of a fracture is often confirmed using imaging. X-ray imaging provides details of the bone, and is the most commonly used imaging technique. Occasionally a CT scan or MRI may be needed to diagnose a stress fractures, which tend to be smaller and less visible on regular x-rays. In some instances, an MRI may be indicated to assess damage to the soft tissue surrounding the fracture.

Treatment

Fracture treatment varies depending on the extent and pattern of fracture. Fractures often initially benefit from the RICE (Rest, Ice, Compress, Elevate) treatment. Patients may also require some medication to help manage their pain. The principles of treating a fracture are:

1. Obtain a satisfactory reduction (make sure the fracture is in an acceptable position). For undisplaced fractures no intervention is required. However, for displaced or unstable fractures manipulation of the bones (reduction) is necessary. For some fracture types surgery is required to reposition the bones.
2. Maintain the fracture reduction (i.e. keep the bones in an acceptable position until they have healed). This usually requires immobilization in a splint or cast. However, for some unstable displaced fractures surgery will be required to stabilize the fracture with screws, plates and screws, or some other type of orthopaedic hardware (ex. an intramedullary nail).
3. Rehabilitate the injured extremity. The fracture and the associated injuries combined with the immobilization and disuse of the extremity requires that extensive rehabilitation of the extremity be undertaken once the fracture has healed. The goals of this rehabilitation is to regain muscle strength, joint flexibility, and overall function of the extremity. This rehabilitation period can take many months

Edited July 28th, 2024