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

Signs and symptoms

Although bone tissue itself contains no nociceptors, bone fracture is painful for several reasons

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
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 callusis 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,] 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.
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. 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.

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[edit]

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
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.
FragmentsIncomplete 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.

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 thoracolumbar 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.[6]
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.
Boxer's fracture a fracture at the neck of a metacarpal
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
Toddler's fracture an undisplaced and spiral fracture of the distal third to distal half of the tibia
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.
 Bosworth fracture a fracture with an associated fixed posterior dislocation of the proximal fibular
fragment which becomes trapped behind the posterior tibial tubercle. The injury is caused by
severe external rotation of the ankle.
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
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
Calcaneal fracture
Classifications named after people

"Denis classification" for spinal fractures

"Frykman classification" for forearm fractures (fractures of radius and ulna)
"Gustilo open fracture classification"
"Letournel and Judet Classification" for Acetabular fractures
"Neer classification" for humerus fractures
Seinsheimer classification, Evans-Jensen classification, Pipkin classification and Garden classification for hip
fractures

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 openversus 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.
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 methodwhich 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.
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 ionsproduced can damage
the bone locally and may cause systemic effects as well.
Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results
however do not support its effectiveness.
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.

References

Jump up^ Marshall, S.T. & Browner, B.D. (2012) [1st. Pub. 1956]. "Chapter 20: Emergency care of
musculoskeletal injuries". In Townsend, Courtney M. Jr. Sabiston textbook of surgery: the biological basis of
modern surgical practice. Elsevier. pp. 480520. ISBN 978-1-4377-1560-6.

1. Jump up^ MedicineNet Fracture Medical Author: Benjamin C. Wedro, MD, FAAEM.
2. Jump up^ Sloan A, Hussain I, Maqsood M, Eremin O, El-Sheemy M (2010). "The effects of smoking on
fracture healing". Surgeon. 8 (2): 1116. doi:10.1016/j.surge.2009.10.014. PMID 20303894