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 risk of wound infection.
- Partial (Incomplete): a fracture that neither completely separates the bone nor traverses the entire length of the bone on any axis.
- 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
- Avulsion: occur when a tendon or ligament pulls on the bone and causes a crack in the bone.
- Comminuted: a complete fracture with several bone pieces or fragments present at the site of the fracture.
- Compression: occur when the bone is crushed and therefore looks flatter.
- Greenstick: an incomplete fracture that most commonly occurs during infancy or childhood, when the bones are still soft. A greenstick fracture occurs when the soft bone bends and one side breaks, but the crack does not extend across the entire bone.
- Impacted: in impacted fractures, the broken bones driven into each other.
- Oblique: a complete fracture in which the break pattern is slanted or diagonal.
- Spiral: spiral fractures are complete fractures that occur when a twisting or rotating force is put on the bone.
- Transverse: a complete fracture in which the break pattern is a straight, “transverse” line.
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
Upon physical examination, patients will have difficulty utilizing the fractured 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, where they bone penetrates 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:
- 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.
- 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. intramedullary nail).
- 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 March 16th, 2021