Fracture of Bone - Types, Mechanism, Symptoms

Fracture of Bones is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may be broken into several pieces.^[rx] A bone fracture may 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, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.^[rx]

Types of Fracture of Bones

According to 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 that has been made weak by some underlying disease is called a pathological fracture. e.g., a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause of pathological fracture.
Periprosthetic fracture – This is a fracture at the point of mechanical weakness at the end of an implant

According to Soft-tissue involvement

Closed fractures are those in which the overlying skin is intact
Open/compound fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose the bone to contamination. Open injuries carry a higher risk of infection.
- Clean fracture
- Contaminated fracture

According to Displacement

Non-displaced
Displaced
- Translated, or ad latus, with sideways displacement.^[rx]
- Angulated
- Rotated
- Shortened

According to 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 that 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

According to Fragments Involvement

An incomplete fracture – This is 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.
A complete fracture – This is a fracture in which bone fragments separately.
A comminuted fracture – This is a fracture in which the bone has broken into several pieces.

According to Shape Bone Fractures

To classify your bone fracture, your doctor will see where the bone has been broken and the shape or pattern of the break. A bone fracture can take several different forms, which will ultimately dictate your treatment. Here are some of the most common:

Open Fracture – In this injury, the bone breaks through the skin, causing a severe wound. Also called a compound fracture, an open fracture should be tended to immediately to prevent infection.
Stress Fracture – Stress fractures look like a hairline crack in the bone and can be hard to see on a regular X-ray. Runners are prone to stress fractures because of the repetitive motion of hitting the pavement.
Greenstick Fracture – In a greenstick fracture, the bone bends and breaks, but remains in one piece. This is often seen in children due to their softer, more flexible bones.
Transverse Fracture – A transverse fracture is characterized by a horizontal break across the bone. It is often the result of a traumatic event like a car accident.
Oblique Fracture – In an oblique fracture, the break has a curved or angled pattern within the bone.
Comminuted Fracture – When the bone shatters into three or more pieces it’s known as a comminuted fracture. Sometimes, bone fragments break away and embed in the site of the fracture. High-impact trauma such as a car accident typically causes a comminuted fracture.
Linear Fracture – Instead of a horizontal break across the bone, a linear fracture is vertical and parallel to the sides of the bone.
Compression Fracture – Compression fractures are the result of the crushing of the bone. This type of fracture typically occurs in the spine when the vertebrae collapse because of bone loss due to osteoporosis.
Displaced Fracture – In most fractures, the bone breaks but remains in alignment. With a displaced fracture, the bone breaks into two or more pieces and is shifted out of alignment due to the force of the trauma.
Spiral Fracture – The defining characteristic of a spiral fracture is a break that spirals around the bone. It’s frequently seen in the long bones of the body, such as the femur, tibia, or fibula in the legs. The most common causes of a spiral fracture are accidents or sports injuries.

Fracture types

Avulsion fracture
Articular surface injuries
- Bone contusion
- Chondral fracture
- Subchondral fracture
- Subchondral insufficiency fracture

Osteochondral fracture

Complete fracture
Transverse fracture
Oblique fracture
Spiral fracture
Longitudinal fracture
Comminuted fracture
segmental fracture
Incomplete fracture
- Bowing fracture
- Buckle fracture (torus)
- Greenstick fracture
Compound fracture
- Gustilo Anderson classification (compound fracture)
Pathological fracture
Stress fracture
- insufficiency fracture
- fatigue fracture
  - grey cortex sign

Fracture displacement

Fracture translation > off-ended fracture
Fracture angulation
Fracture rotation
Fracture length
- distraction
- impaction
- shortening

Skull Fractures

The base of skull fractures
Occipital condyle fracture
Temporal bone fractures
- Longitudinal fractures
- Transverse fractures
- Mixed fractures
- Transsphenoidal basilar skull fracture
Skull vault fractures
- Depressed skull fracture
- Ping pong skull fracture

Facial fractures

Fractures involving a single facial buttress
Alveolar process fractures
Frontal sinus fracture
Isolated zygomatic arch fractures
Mandibular fracture
Nasal bone fracture
Orbital blow-out fracture
Paranasal sinus fractures

Complex fractures

Complex midfacial fracture
Le Fort fractures
Naso-orbitoethmoid (NOE) complex fracture
Zygomaticomaxillary complex fracture

Cervical spine fracture classification systems

AO classification of upper cervical injuries
AO classification of subaxial injuries
Anderson and D’Alonzo classification (odontoid fracture)
Levine and Edwards classification (hangman fracture)
Roy-Camille classification (odontoid process fracture )
Allen and Ferguson classification (subaxial spine injuries)
subaxial cervical spine injury classification (SLIC)

Thoracolumbar spinal fracture classification systems

AO classification of thoracolumbar injuries
Magerl classification
McAfee classification
Thoracolumbar injury classification and severity score (TLICS)
Limbus fractures

- Three-column concept of spinal fractures (Denis classification)
- Classification of sacral fractures
- AO classification of sacral injuries

Cervical spine fractures

clay shoveler’s fracture
dens fracture
hangman fracture
Jefferson fracture
extension teardrop fracture
flexion teardrop fracture
cervical spine floating pillar

Thoracic spine fractures

Chance fracture
Transverse process fracture
Spondylolysis
- lumbar spine fractures
- sacral fractures

Spinal fracture types

Burst fracture
Chance fracture
Clay-shoveler fracture
Chalk stick fracture
Dens fracture
Extension teardrop fracture
Flexion teardrop fracture
Hangman fracture
Jefferson fracture
Vertebra plana
Wedge fracture

Rib fractures

Flail chest
Stove-in chest
Sternal fractures

Upper limb fractures classification

Rockwood classification (acromioclavicular joint injury)
Neer classification (proximal humeral fracture)
AO classification (proximal humeral fracture)
Milch classification (lateral humeral condyle fracture)
Weiss classification (lateral humeral condyle fracture)
Bado classification of Monteggia fracture-dislocations (radius-ulna)
Mason classification (radial head fractures
Frykman classification (distal radial fracture)

Mayo classification (scaphoid fracture)

Hintermann classification (gamekeeper’s thumb)
Eaton classification (volar plate avulsion injury)
Keifhaber-Stern classification (volar plate avulsion injury)

Upper limb fractures by region

Shoulder

Clavicular fracture
Scapular fracture
Acromion fracture
Coracoid process fracture
Glenoid fracture
- Bankart lesion
- reverse Bankart lesion

Humeral head fracture

Hill-Sachs lesion
reverse Hill-Sachs lesion
proximal humeral fracture
humeral neck fracture

Arm

Humeral shaft fracture

Elbow

Humeral condyle fracture
Lateral humeral condyle fracture
Medial humeral condyle fracture
Epicondyle fracture
Medial epicondyle fracture
Lateral epicondyle fracture
Olecranon fracture
Supracondylar fracture (extension)
Supracondylar fracture (flexion)
Radial head fracture
Radial neck fracture

Forearm

Forearm fracture-dislocation
Essex-Lopresti fracture-dislocation
Galeazzi fracture-dislocation
Monteggia fracture-dislocation
Forearm fracture
nightstick fracture

Wrist > distal radial fracture

Chauffeur fracture
Colles fracture
Smith fracture
Barton fracture
reverse Barton fracture

Distal ulnar fracture

Ulnar styloid fracture
Carpal bones
Humpback deformities
Scaphoid fracture
Scaphoid non-union
A scaphoid nonunion advanced collapse

Lunate fracture

Perilunate fracture-dislocation
Lunate dislocation
Capitate fracture
Triquetral fracture
Pisiform fracture
Hamate fracture
Hook of hamate fracture
Trapezoid fracture
Trapezium fracture

Hand

Metacarpal fractures > boxer fracture & reverse Bennett fracture-dislocation

Fractures of the thumb

Gamekeeper’s thumb
Epibasal fracture of the thumb
Rolando fracture
Bennett fracture-dislocation

Phalanx fractures

Proximal phalanx fracture
Middle phalanx fracture
Volar plate avulsion injury
Distal phalanx fracture
- Jersey’s finger
- mallet finger

Lower limb fractures > classification by region

pelvis
Judet and Letournel classification (acetabular fracture)
Young and Burgess’s classification of pelvic ring fractures

Hip

Pipkin classification (femoral head fracture)
Garden classification (hip fracture)
American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
Cooke and Newman classification (periprosthetic hip fracture)
Johansson classification (periprosthetic hip fracture)
Vancouver classification (periprosthetic hip fracture)

Femoral

Winquist classification (femoral shaft fracture)

Knee

Schatzker classification (tibial plateau fracture)
Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)

Tibia/fibula

Watson-Jones classification (tibial tuberosity avulsion fracture)

Ankle

Lauge-Hansen classification (ankle injury)
Danis-Weber classification (ankle fracture)

Foot

Berndt and Harty classification (osteochondral lesions of the talus)
Sanders CT classification (calcaneal fracture)
Hawkins classification (talar neck fracture)
Myerson classification (Lisfranc injury)
Nunley-Vertullo classification (Lisfranc injury)

Lower limb fractures by region> pelvic fracture

Malgaigne fracture
Wind-swept pelvis fracture
Pelvic bucket handle fracture
Pelvic insufficiency fracture
Parasymphyseal insufficiency fracture
anterior inferior iliac spine avulsion
Duverney fracture
Open book fracture
Pubic rami fracture
Anterior superior iliac spine (ASIS) avulsion

Sacral fracture

Sacral insufficiency fractures
Honda sign

Hip

Acetabular fracture
Femoral head fracture
Femoral neck fracture
- subcapital fracture
- transcervical fracture
- basicervical fracture

Trochanteric fracture

Pertrochanteric fracture
Intertrochanteric fracture
Subtrochanteric fracture

Thigh

Mid-shaft fracture
Bisphosphonate-related fracture

Knee > avulsion fractures

Segond fracture
Reverse Segond fracture
Anterior cruciate ligament avulsion fracture
Posterior cruciate ligament avulsion fracture
Arcuate complex avulsion fracture (arcuate sign)
Biceps femoris avulsion fracture
Iliotibial band avulsion fracture
Semimembranosus tendon avulsion fracture
Steeda fracture (MCL avulsion fracture)
Patella fracture
Tibial plateau fracture

leg

Tibial tuberosity avulsion fracture
Tibial shaft fracture
Fibular shaft fracture
Maisonneuve fracture

Ankle

Bimalleolar fracture
Trimalleolar fracture
Triplane fracture
Tillaux fracture
Bosworth fracture
Pilon fracture
Wagstaffe-Le Forte fracture

Foot

Tarsal bones
Chopart fracture
Calcaneal fracture
Lover’s fracture
Calcaneal tuberosity avulsion fracture

Talus fracture

Talar body fractures
Talar dome osteochondral fracture
Posterior talar process fracture
Lateral talar process fracture
Talar neck fracture
- aviator fracture
- talar head fracture
- navicular fracture
- medial cuneiform fracture
- intermediate cuneiform fracture
- lateral cuneiform fracture
- cuboid fracture
- nutcracker fracture

Metatarsal Bones

March fracture
Lisfranc fracture-dislocation
5th metatarsal fracture
Stress fracture of the 5th metatarsal
Jones fracture
Pseudo-Jones fracture
Avulsion fracture of the proximal 5th metatarsal
phalanges

Classification parameter In Broadly

Fracture types

- - avulsion fracture
  - articular surface injuries
    - bone contusion
    - chondral fracture
    - subchondral fracture
      - subchondral insufficiency fracture
    - osteochondral fracture
  - complete fracture
    - transverse fracture
    - oblique fracture
    - spiral fracture
    - longitudinal fracture
    - comminuted fracture
    - segmental fracture
  - incomplete fracture
    - bowing fracture
    - buckle fracture (torus)
    - greenstick fracture
  - infraction
  - compound fracture
    - Gustilo Anderson classification (compound fracture)
  - pathological fracture
  - stress fracture
    - insufficiency fracture
    - fatigue fracture
      - grey cortex sign
- fracture displacement
  - fracture translation
    - off-ended fracture
  - fracture angulation
  - fracture rotation
  - fracture length
    - distraction
    - impaction
    - shortening
skull fractures[–]
- the base of skull fractures
  - occipital condyle fracture
  - temporal bone fractures
    - longitudinal fractures
    - transverse fractures
    - mixed fractures
  - transsphenoidal basilar skull fracture
- skull vault fractures
  - depressed skull fracture
  - ping pong skull fracture
facial fractures[–]
- fractures involving a single facial buttress
  - alveolar process fractures
  - frontal sinus fracture
  - isolated zygomatic arch fractures
  - mandibular fracture
  - nasal bone fracture
  - orbital blow-out fracture
  - paranasal sinus fractures
- complex fractures
  - complex midfacial fracture
  - Le Fort fractures
  - naso-orbitoethmoid (NOE) complex fracture
  - zygomaticomaxillary complex fracture
spinal fractures[–]
- classification (AO Spine classification systems)
  - cervical spine fracture classification systems
    - AO classification of upper cervical injuries
    - AO classification of subaxial injuries
    - Anderson and D’Alonzo classification (odontoid fracture)
    - Levine and Edwards classification (hangman fracture)
    - Roy-Camille classification (odontoid process fracture )
    - Allen and Ferguson classification (subaxial spine injuries)
    - subaxial cervical spine injury classification (SLIC)
  - thoracolumbar spinal fracture classification systems
    - AO classification of thoracolumbar injuries
    - Magerl classification
    - McAfee classification
    - thoracolumbar injury classification and severity score (TLICS)
    - limbus fractures
  - three column concept of spinal fractures (Denis classification)
  - classification of sacral fractures
    - AO classification of sacral injuries
- spinal fractures by region
  - cervical spine fractures
    - clay shoveler’s fracture
    - dens fracture
    - hangman fracture
    - Jefferson fracture
    - extension teardrop fracture
    - flexion teardrop fracture
    - cervical spine floating pillar
  - thoracic spine fractures
    - Chance fracture
    - transverse process fracture
    - spondylolysis
  - lumbar spine fractures
  - sacral fractures
- spinal fracture types
  - burst fracture
  - Chance fracture
  - clay-shoveler fracture
  - chalk stick fracture
  - dens fracture
  - extension teardrop fracture
  - flexion teardrop fracture
  - hangman fracture
  - Jefferson fracture
  - vertebra plana
  - wedge fracture
rib fractures[–]
- flail chest
- stove-in chest
sternal fractures
upper limb fractures
- classification
  - Rockwood classification (acromioclavicular joint injury)
  - Neer classification (proximal humeral fracture)
  - AO classification (proximal humeral fracture)
  - Milch classification (lateral humeral condyle fracture)
  - Weiss classification (lateral humeral condyle fracture)
  - Bado classification of Monteggia fracture-dislocations (radius-ulna)
  - Mason classification (radial head fracture)
  - Frykman classification (distal radial fracture)
  - Mayo classification (scaphoid fracture)
  - Hintermann classification (gamekeeper’s thumb)
  - Eaton classification (volar plate avulsion injury)
  - Keifhaber-Stern classification (volar plate avulsion injury)
- upper limb fractures by region[–]
  - shoulder
    - clavicular fracture
    - scapular fracture
      - acromion fracture
      - coracoid process fracture
      - glenoid fracture
        
        Bankart lesion
        
        reverse Bankart lesion
    - humeral head fracture
      - Hill-Sachs lesion
      - reverse Hill-Sachs lesion
    - proximal humeral fracture
    - humeral neck fracture
  - arm
    - humeral shaft fracture
  - elbow
    - humeral condyle fracture
      - lateral humeral condyle fracture
      - medial humeral condyle fracture
    - epicondyle fracture
      - medial epicondyle fracture
      - lateral epicondyle fracture
      - single condyle fractures,
      - bi-column fractures and
      - coronal shear fractures.
    - olecranon fracture
    - supracondylar fracture (extension)
    - supracondylar fracture (flexion)
    - radial head fracture
    - radial neck fracture
  - forearm
    - forearm fracture-dislocation
      - Essex-Lopresti fracture-dislocation
      - Galeazzi fracture-dislocation
      - Monteggia fracture-dislocation
    - forearm fracture
      - nightstick fracture
  - wrist
    - distal radial fracture
      - Chauffeur fracture
      - Colles fracture
      - Smith fracture
      - Barton fracture
      - reverse Barton fracture
    - distal ulnar fracture
      - ulnar styloid fracture
  - carpal bones
    - scaphoid fracture
      - scaphoid non-union
        
        scaphoid non-union advanced collapse
      - humpback deformity
    - lunate fracture
      - perilunate fracture-dislocation
      - lunate dislocation
    - capitate fracture
    - triquetral fracture
    - pisiform fracture
    - hamate fracture
      - hook of hamate fracture
    - trapezoid fracture
    - trapezium fracture
  - hand
    - metacarpal fractures
      - boxer fracture
      - reverse Bennett fracture-dislocation
    - fractures of the thumb
      - Stener lesion
      - skier’s thumb
      - gamekeeper’s thumb
      - epibasal fracture of the thumb
      - Rolando fracture
      - Bennett fracture-dislocation
    - phalanx fractures
      - proximal phalanx fracture
      - middle phalanx fracture
        
        volar plate avulsion injury
        
        Shaft Fracture
        
        Condyle fracture (a.k.a. Head fracture)unicondylar fracture or bicondylar
        
        Phalangeal Neck Fracture
        
        Salter-Harris II Fracture at base of phalanx
        
        Salter-Harris III or IV Fractures
        
        Epiphyseal fractures
        
        Volar Plate injury
      - distal phalanx fracture
        
        Jersey’s finger
        
        Mallet finger
        
        Tuft Fracture (crush injury)
        
        Subungual Hematoma
        
        Nail Bed Lacerations
        
        Distal Interphalangeal Joint Dislocation
        
        Seymour Fracture
lower limb fractures
- classification by region
  - pelvis
    - Judet and Letournel classification (acetabular fracture)
    - Young and Burgess’s classification of pelvic ring fractures
  - hip
    - Pipkin classification (femoral head fracture)
    - Garden classification (hip fracture)
    - American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
    - Cooke and Newman classification (periprosthetic hip fracture)
    - Johansson classification (periprosthetic hip fracture)
    - Vancouver classification (periprosthetic hip fracture)
  - femoral
    - Winquist classification (femoral shaft fracture)
  - knee
    - Schatzker classification (tibial plateau fracture)
    - Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)
  - tibia/fibula
    - Watson-Jones classification (tibial tuberosity avulsion fracture)
  - ankle
    - Lauge-Hansen classification (ankle injury)
    - Danis-Weber classification (ankle fracture)
  - foot
    - Berndt and Harty classification (osteochondral lesions of the talus)
    - Sanders CT classification (calcaneal fracture)
    - Hawkins classification (talar neck fracture)
    - Myerson classification (Lisfranc injury)
    - Nunley-Vertullo classification (Lisfranc injury)
- lower limb fractures by region
  - pelvic fracture
    - Malgaigne fracture
    - wind-swept pelvis fracture
    - pelvic bucket handle fracture
    - pelvic insufficiency fracture
      - parasymphyseal insufficiency fracture
    - anterior inferior iliac spine avulsion
    - Duverney fracture
    - open book fracture
    - pubic rami fracture
    - anterior superior iliac spine (ASIS) avulsion
  - sacral fracture
    - sacral insufficiency fractures
      - Honda sign
  - hip
    - acetabular fracture
    - femoral head fracture
    - femoral neck fracture
      - subcapital fracture
      - transcervical fracture
      - basicervical fracture
    - trochanteric fracture
      - pertrochanteric fracture
      - intertrochanteric fracture
      - subtrochanteric fracture
  - thigh
    - mid-shaft fracture
    - bisphosphonate-related fracture
  - knee
    - avulsion fractures
      - Segond fracture
      - reverse Segond fracture
      - anterior cruciate ligament avulsion fracture
      - posterior cruciate ligament avulsion fracture
      - arcuate complex avulsion fracture (arcuate sign)
      - biceps femoris avulsion fracture
      - iliotibial band avulsion fracture
      - semimembranosus tendon avulsion fracture
      - Steeda fracture (MCL avulsion fracture)
    - patella fracture
    - tibial plateau fracture
  - leg
    - tibial tuberosity avulsion fracture
    - tibial shaft fracture
    - fibular shaft fracture
    - Maisonneuve fracture
  - ankle
    - bimalleolar fracture
    - trimalleolar fracture
    - triplane fracture
    - Tillaux fracture
    - Bosworth fracture
    - pilon fracture
    - Wagstaffe-Le Forte fracture
  - foot
    - tarsal bones
      - Chopart fracture
      - calcaneal fracture
        
        lover’s fracture
        
        calcaneal tuberosity avulsion fracture
      - talus fracture
        
        talar body fractures
        
        talar dome osteochondral fracture
        
        posterior talar process fracture
        
        lateral talar process fracture
        
        talar neck fracture
        
        aviator fracture
        
        talar head fracture
      - navicular fracture
      - medial cuneiform fracture
      - intermediate cuneiform fracture
      - lateral cuneiform fracture
      - cuboid fracture
        
        nutcracker fracture
    - metatarsal bones
      - general
        
        march fracture
        
        Lisfranc fracture-dislocation
      - 5th metatarsal fracture
        
        stress fracture of the 5th metatarsal
        
        Jones fracture
        
        pseudo-Jones fracture
        
        avulsion fracture of the proximal 5th metatarsal
    - phalanges

Distal phalanx injuries

Tuft: Simple or comminuted fracture
Soft tissue distortion may suggest nailbed injury shift: Longitudinal or transverse fracture
Intraarticular (DIP) injury
Jersey finger: Distal FDP injury; ± volar avulsion fragment; unable to flex the DIP
Mallet finger: DIP flexion due to terminal extensor tendon injury; ± dorsal avulsion fragment
DIP joint dislocation: Typically dorsal or lateral
Often associated with significant soft tissue injury due to tight soft tissue sleeve in distal digits

Epiphyseal injuries

Child: Salter-Harris type I or II
Adolescent: Salter-Harris type II or III
Displacement of fracture fragment may mimic dislocation

Middle/proximal phalanx injuries

Intraarticular (PIP) injury

Condylar: Unicondylar, bicondylar, or comminuted fracture may be missed clinically because the finger still flexes. Associated with significant soft tissue injury
Base: Avulsion or impaction fracture
Boutonnière injury: PIP flexion with DIP extension due to extensor tendon central slip injury; ± dorsal avulsion middle phalanx base solar plate injury: Typically distal volar plate injured; ± volar avulsion of the base of middle phalanx
Collateral ligament injury: Asymmetric joint widening; radial collateral ligament (RCL) > UCL; ± lateral avulsion fracture
Comminuted impaction (pilon) fracture: Central depression with splaying of articular margin lateral plateau fracture: Typically involves middle phalanx base
Dislocation: Dorsal PIP is the most common
Coach’s finger: Dorsal dislocation of middle phalanx base on proximal phalanx head; ± volar plate injury
Physeal fractures: 85-90% are Salter-Harris type II Typically small finger with medial angulation

Extraarticular fractures

Sub capital: Common in children; frequently overlooked
Head fragment may displace and rotate 90° dorsally
Spiral/oblique fracture: Proximal phalanx is the most common
Transverse fracture: Middle phalanx is the most common

MCP injury of fingers

Proximal phalanx dorsal dislocation/subluxation; ± avulsion or osteochondral shear fracture joint space widening; medial or lateral angulation. Look for sesamoid interposed in MCP, which Indicates volar plate injury

Thumb MCP injury

Joint subluxation or widening suggests collateral ligament injury
Asymmetric widening of medial or lateral joint > 30° with flexion/extension difference between injured and uninjured joint > 15° suggests ligament injury
UCL injuries 10x more frequent than RCL injuries
Look for associated fracture fragment, typically from the ulnar base of proximal phalanx
Mallet thumb: Rare; extensor pollicis longus tear; ± dorsal avulsion

Symptoms of Fracture of Bones

Although bone tissue itself contains no nociceptors, the bone fracture is painful for several reasons:^[rx]

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 broken periosteal blood vessels evokes pressure pain.
Involuntary muscle spasms trying to hold bone fragments in place.
Hematoma on the fracture site.

Damage to adjacent structures such as nerves, muscles or blood vessels, spinal cord, and nerve roots (for spine fractures), or cranial contents (for skull fractures) may cause other specific signs and symptoms.

$fracture of bone$

Diagnosis

History

Your doctor in the emergency department may ask the following questions

How – How was the fracture created, and, if chronic, why is it still open? (underlying etiology)
When – How long has this fracture been present? (e.g., chronic less than 1 month or acute, more than 6 months)
What – What anatomy and structure do it involve? (e.g., epidermis, dermis, subcutaneous tissue, fascia, muscle, tendon, bone, arteries, nerves). What comorbidities, economic or social factors do the patient have which might affect their ability to heal the fracture?
Where – Where on the body parts is it located? Is it in an area that is difficult to offload, complicated, or keep clean? Is it in an area of high skin tension? Is it near any vital organ and structures such as a major artery?
What is your Past – Has your previous medical history of fracture? Are you suffering from any chronic disease, such as hypertension, blood pressure, diabetes mellitus, or previous major surgery? What kind of medicine did you take? What is your food habits, geographic location, Alcohol, tea, coffee consumption habit, anabolic steroid uses for athletes, etc?

Physical

Physical examination is done by your doctor, consisting of palpation of the fracture site, eliciting boney tenderness, edema, and swelling. If the fracture is in the dept of a joint, the joint motion, and normal movement will aggravate the pain.

Inspection – Your doctor also checks superficial tissue, and skin color, involving or not only the epidermal layer or Partial-thickness affects the epidermis and extend into the dermis, but full thickness also extends through the dermis and into the adipose tissues or full-thickness extends through the dermis, and adipose exposes muscle, bone, evaluate and measure the depth, length, and width of the fracture. Access surrounding skin tissue, fracture margins for tunneling, rolled, undermining fibrotic changes, and if unattached and evaluate for signs and symptoms of infection warm, pain, and delayed healing.
Palpation – Physical examination may reveal tenderness to palpation, swelling, edema, tenderness, worm, temperature, open fracture, closed fracture, microtrauma, and ecchymosis at the site of fracture. Condition of the surrounding skin and soft tissue, quality of vascular perfusion and pulses, and the integrity of nerve function.
Motor function – Your doctor may ask the patient to move the injured area to assist in assessing muscle, ligament, and tendon function. The ability to move the joint means only that the muscles and tendons work properly, and does not guarantee bone integrity or stability. The concept that “it can’t be fractured because you can move it” is not correct. The jerk test and manual test are also performed to investigate the motor function.
Sensory examination – assesses sensations such as light touch, worm, paresthesia, itching, numbness, and pinprick sensations, in its fracture side. Sensory 2-point discrimination
Range of motion – A range of motion examination of the fracture associate joint and it’s surrounding joint may help assess the muscle, tendon, ligament, and cartilage stability. Active assisted, actively resisted exercises are performed around the injured area joint.
Blood pressure and pulse check – Blood pressure is the term used to describe the strength of blood with which your blood pushes on the sides of your arteries as it’s pumped around your body. An examination of the circulatory system, feeling for pulses, and blood pressure, and assessing how quickly blood returns to the tip of a toe to the heart and it is pressed the toe turns white (capillary refill).

Lab Test

Laboratory tests should be done as an adjunct to the overall medical status for surgical treatment.

CBC, ESR test
Random blood sugar, glucose, and routine diabetes test if the patient has diabetes mellitus.
Microscopic urine examination test, and stool test.
ECG, EKG test for heart abnormality is present
Ultrasonography test in some cases.
Normalized hemoglobin, hematocrit test
Coagulation profile with bleeding time and coagulation time test, prothrombin time (PT) test for surgery if needed,
Partial thromboplastin time (PTT), and platelet counts will be needed for operative intervention.
Serum creatinine test,
Serum lipid profile
Serum uric acid test

Treatment

First Aid

First aid steps include:

Check the person’s airway and breathing. If necessary, call 911 and begin rescue breathing, CPR, or bleeding control.
Keep the person still and calm.
Examine the person closely for other injuries.
In most cases, if medical help responds quickly, allow the medical personnel to take further action.
If the skin is broken, it should be treated right away to prevent infection. Call emergency help right away. DO NOT breathe on the wound or probe it. Try to cover the wound to avoid further contamination. Cover with sterile dressings if they are available. Don’t try to line up the fracture unless you are medically trained to do so.
If needed, immobilize the broken bone with a splint or sling. Possible splints include a rolled-up newspaper or strips of wood. Immobilize the area both above and below the injured bone.
Apply ice packs to reduce pain and swelling. Elevating the limb can also help to reduce swelling.
Take steps to prevent shock. Lay the person flat, elevate the feet about 12 inches (30 centimeters) above the head, and cover the person with a coat or blanket. However, DO NOT move the person if a head, neck, or back injury is suspected.
Check the person’s blood circulation. Press firmly over the skin beyond the fracture site. (For example, if the fracture is in the leg, press on the foot). It should first blanch white and then “pink up” in about 2 seconds. Signs that circulation is inadequate include pale or blue skin, numbness or tingling, and loss of pulse.

If circulation is poor and trained personnel are NOT quickly available, try to realign the limb into a normal resting position. This will reduce swelling, pain, and damage to the tissues from lack of blood.

Do no HARM for 72 hours after injury

Heat – Heat applied to fracture and injured side by hot baths, electric heat, saunas, heat packs, etc has the opposite effect on the blood flow. Heat may cause more fluid accumulation in the fracture joints by encouraging blood flow. Heat should be avoided when inflammation is developing in the acute stage. However, after about 72 hours, no further inflammation is likely to develop and heat can be soothing.
Alcohol – stimulates the central nervous system which can increase bleeding and swelling and decrease healing.
Running and movement – Running and walking may cause further damage, and causes healing delay.
Massage – A massage also may increase bleeding and swelling. However, after 72 hours of your fracture, you can take a simple message, and applying heat may be soothing the pain.

Medication

The following medications may be considered by your doctor to relieve acute and immediate pain, long-term treatment

Antibiotic – Cefuroxime or Azithromycin, Flucloxacillin or any other cephalosporin/quinolone, meropenem antibiotic must be used to prevent infection or clotted blood removal to prevent further swelling, inflammation, and edema.
NSAIDs – Prescription-strength drugs that reduce both pain and inflammation. Pain medicines and anti-inflammatory drugs help to relieve pain and stiffness, allowing for increased mobility and exercise. There are many common over-the-counter medicines called non-steroidal anti-inflammatory drugs (NSAIDs). They include first-choice NSAIDs is Ketorolac, then Etoricoxib, then Aceclofenac, and naproxen. As you are taking pain medication or NSAIDs, your doctor must prescribe a standard anti-ulcer drug, such as omeprazole, pantoprazole, esomeprazole, dexlansoprazole, etc.
Muscle Relaxants – These medications provide relief from spinal muscle spasms and spasticity. Muscle relaxants, such as baclofen, tolperisone, eperisone, methocarbamol, carisoprodol, and cyclobenzaprine, may be prescribed to control postoperative muscle spasms, spasticity, stiffness, and contracture.
Calcium & vitamin D3 – To improve bone health, blood clotting, helping muscles to contract, regulating heart rhythms, nerve functions, and healing fractures. As a general rule, too absorbed more minerals for men and women aged 50 and older should consume 1,200 milligrams of calcium a day, and 600 international units of vitamin D a day to heal back pain, fractures, and osteoarthritis.
Neuropathic Agents – Drugs(pregabalin & gabapentin) that address neuropathic—or nerve-related—pain. This includes burning, numbness, tingling sensation, and paresthesia .
Glucosamine & Diacerein, Chondroitin sulfate – can be used to tighten the loose tendon, cartilage, ligament, and cartilage, ligament regenerates cartilage or inhabits the further degeneration of cartilage, ligament. The dosage of glucosamine is 15oo mg per day in divided dosage and chondroitin sulfate is approximately 500mg per day in different dosages, and diacerein minimum of 50 mg per day may be taken if the patient suffers from osteoarthritis, rheumatoid arthritis, and any degenerative joint disease.[rx]
Topical Medications and essential oil – These prescription-strength creams, gels, ointments, patches, and sprays help relieve pain and inflammation in acute trauma, pain, swelling, and tenderness through the skin. If the fracture is closed and not open fracture then you can use this item.
Antidepressants – A drug that blocks pain messages from your brain and boosts the effects of endorphins in your body’s natural painkillers. It also helps in neuropathic pain, anxiety, tension, and proper sleep.
Corticosteroids – Also known as oral steroids, these medications reduce inflammation. To heal the nerve inflammation and clotted blood in the joints.
Dietary supplement– To eradicate the healing process from fracture your body needs a huge amount of vitamin C, and vitamin E. From your dietary supplement, you can get it, and also need to remove general weaknesses & improve your health.
Cough Syrup– If your doctor finds any chest congestion or fracture-related injury in your chest, dyspnoea, or post-surgical breathing problem, then advise you to take bronchodilator cough syrup.

Sometimes fractures must be reduced and repaired surgically, as for the following:

Open fractures: Because the skin was broken, bacteria and debris can enter the body. Doctors must carefully clean the area around the fracture to remove all traces of debris. Doing so reduces the risk of infection.
Displaced fractures that cannot be aligned or kept aligned by closed reduction: When a piece of bone has shifted or a tendon is in the way, doctors may not be able to realign the broken bones by manipulating them from the outside (closed reduction). Or the fracture can be realigned using closed reduction, but the muscles pull on the pieces of bone and keep them from staying in place.
Joint surface fractures: These fractures extend into a joint, fracturing the cartilage at the ends of the bones in the joint. To prevent people from developing arthritis later, doctors must almost perfectly realign the fractured cartilage. Realignment can be more precise when it is done surgically.
Pathologic fractures in a bone weakened by cancer: Bone weakened by cancer may not heal normally after a fracture. Surgery may be needed to prevent the fragments of bone from becoming displaced. Also, stabilizing the joint surgically reduces the pain and enables people to use the joint more quickly.
Fractures known to require surgery: Certain kinds of fractures (such as hip fractures and thighbone fractures) are known to heal more rapidly and have a better outcome when they are surgically repaired.
Fractures that would otherwise require a long period of immobilization or bed rest: Surgery shortens the time people have to stay in bed. For example, surgery enables people who have had a hip fracture to get out of bed and begin walking soon after the operation, often as soon as the first day after surgery (with the help of a walker).
Complicated fractures: Surgery may be required to treat certain injuries that occur with a fracture, such as damaged arteries or severed nerves
In open reduction with internal fixation (ORIF), surgery is done to restore the bone’s original shape and alignment. X-rays are used to help surgeons see how to align the bones. After making an incision to expose the fracture, the surgeon uses special instruments to align the bone fragments. Then, the fragments are held in place using some combination of metal wires, pins, screws, rods, and plates. For example, metal plates may be shaped as needed and attached to the outside of the bone with screws. Metal rods may be inserted from one end of the bone into the interior of the bone (marrow). These hardware devices are made of stainless steel, high-strength alloy metal, or titanium. The devices that have been made in the last 15 to 20 years do not interfere with the strong magnets used in magnetic resonance imaging (MRI). Most do not set off security devices at airports. Some of these devices are permanently left in place, and some are removed after the fracture has healed.
Joint replacement (arthroplasty) may be needed, usually when fractures severely damage the upper end of the thighbone (femur), which is part of the hip joint, or the upper arm bone (humerus), which is part of the shoulder joint.
In bone grafting, doctors use chips of bone taken from another part of the body (such as the pelvis). This procedure may be done immediately if the gap between pieces of bone is too large. It may be done later if the healing process has slowed (delayed union) or stopped (nonunion).

What To Eat and What to avoid

Eat Nutritiously During Your Recovery

All bones and tissues in the body need certain micronutrients to heal properly and promptly. Eating a nutritious and balanced diet that includes lots of minerals and vitamins is proven to help heal broken bones and all types of fractures. Therefore, focus on eating lots of fresh food produce (fruits and veggies), whole grains, cereal, beans, lean meats, seafood, and fish to give your body the building blocks needed to properly repair your fracture. In addition, drink plenty of purified mineral water, milk, and other dairy-based beverages to augment what you eat.

Broken bones or fractured bones need ample minerals (calcium, phosphorus, magnesium, boron, selenium, omega-3) and protein to become strong and healthy again.
Excellent sources of minerals/protein include dairy products, tofu, beans, broccoli, nuts and seeds, sardines, sea fish, and salmon.
Important vitamins that are needed for bone healing include vitamin C (needed to make collagen your body’s essential element), vitamin D (crucial for mineral absorption, or machine for mineral absorber from your food), and vitamin K (binds calcium to bones and triggers more quickly collagen formation).
Conversely, don’t consume food or drink that is known to impair bone/tissue healing, such as alcoholic beverages, sodas, fried fast food, most fast food items, and foods made with lots of refined sugars and preservatives.

Complications

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.

Complications of fractures may be classified into three broad groups, depending upon their time of occurrence. These are as follows –

Immediate complications – occur at the time of the fracture.
Early complications – occur in the initial few days after the fracture.
Late complications – occur a long time after the fracture.

Immediate complications	Early complications	Late complications
Systemic Hypovolaemic shock	Systemic Hypovolaemic shock ARDS – Adult respiratory distress syndrome Fat embolism syndrome Deep vein thrombosis Pulmonary syndrome Aseptic traumatic fever Septicemia (in open fracture ) Crush syndrome	Imperfect union of the fracture Delayed union Nonunion Malunion Cross union
Local Injury to major vessels Injury to muscles and tendons Injury to joints Injury to viscera	Local Infection Compartment syndrome	Others Avascular necrosis Shortening Joint stiffness Sudeck’s dystrophy Osteomyelitis Ischaemic contracture Myositis ossificans Osteoarthritis

Fractures can be accompanied by or lead to other problems (complications). However, serious complications are unusual. The risk of serious complications is increased if the skin is torn or if blood vessels or nerves are damaged.

Some complications (such as blood vessel and nerve damage, compartment syndrome, fat embolism, and infections) occur during the first hours or days after the injury. Others (such as problems with joints and healing) develop over time.

Many fractures cause noticeable bleeding around the injury. Rarely, bleeding within the body (internal bleeding) or from an open wound (external bleeding) is massive enough to cause a life-threatening drop in blood pressure ( shock). For example, shock may result when fractures of the thighbone (femur) or pelvis cause severe internal bleeding. If a person is taking a drug to prevent blood clots from forming (an anticoagulant), relatively minor injuries can cause substantial bleeding. A dislocated hip or knee can disrupt blood flow to the leg. Thus, the tissues in the leg may not get enough blood (called ischemia) and may die (called necrosis). If enough tissue dies, part of the leg may have to be amputated. Sometimes fractures of the elbow or upper arm can disrupt blood flow to the forearm, causing similar problems. A disrupted blood supply may not cause any symptoms until several hours after the injury.

Sometimes nerves are stretched, bruised, or crushed when a bone is fractured. A direct blow can bruise or crush a nerve. These injuries usually heal on their own over weeks to months to years, depending on the severity of the injury. Some nerve injuries never heal completely.

Rarely, nerves are torn, sometimes by sharp bone fragments. Nerves are more likely to be torn when the skin is torn. Torn nerves do not heal on their own and may have to be repaired surgically.

Pulmonary embolism is the most common severe complication of serious fractures of the hip or pelvis. It occurs when a blood clot forms in a vein, breaks off (becoming an embolus), travels to a lung, and blocks an artery there. As a result, the body may not get enough oxygen. Having a hip fracture greatly increases the risk of pulmonary embolism because it involves

Injury to the leg, where most of the clots that cause pulmonary embolism form
Forced immobility (having to stay in bed) for hours or days, slowing blood flow and thus giving clots the opportunity to form
Swelling around the fracture also slows blood flow in the veins

About one-third of people who die after a hip fracture dies of pulmonary embolism. Pulmonary embolism is much less common when the lower leg is broken and is very rare when the arm is broken.

Fat embolism rarely occurs. It can occur when long bones (such as the thighbone) are fractured and release fat from the bone’s interior (marrow). The fat may travel through the veins, lodge in the lungs, and block a blood vessel there, causing pulmonary embolism. As a result, the body does not get enough oxygen, and people may become short of breath and have chest pain. Their breathing may become rapid and shallow, and their skin may become mottled or blue.

Rarely, compartment syndrome develops. For example, it may develop when injured muscles swell a lot after an arm or a leg is broken. Because the swelling puts pressure on nearby blood vessels, blood flow to the injured limb is reduced or blocked. As a result, tissues in the limb may be damaged or die, and the limb may have to be amputated. Without prompt treatment, the syndrome can be fatal. Compartment syndrome is more likely to occur in people who have certain fractures of the lower leg, certain arm fractures, or a Lisfranc fracture (a type of foot fracture).

If the skin is torn when a bone is broken, the wound may become infected, and the infection may spread to the bone (called osteomyelitis, which is very difficult to cure).

Fractures that extend into a joint usually damage the cartilage at the ends of bones in the joint (called joint surfaces). Normally, this smooth, tough, protective tissue enables joints to move smoothly. Damaged cartilage tends to scar, causing osteoarthritis, which makes joints stiff and limits their range of motion. The knee, elbow, and shoulder are particularly likely to become stiff after an injury, especially in older people.

Physical therapy is usually needed to prevent stiffness and help the joint move as normally as possible. Surgery is often needed to repair the damaged cartilage. After such surgery, the cartilage is less likely to scar, and if scarring occurs, it tends to be less severe.

Some fractures can make a joint unstable, increasing the risk of repeated injuries and osteoarthritis. Appropriate treatment, often including a cast or splint, can help prevent permanent problems.

In children, if a growth plate in a leg is fractured, the affected leg may not grow normally and may be shorter than the other leg. Growth plates, which are made of cartilage, enable bones to lengthen until children reach their full height. If a fracture does not involve the growth plate, it may stimulate bone growth from the fracture site itself. If it stimulates growth, the fractured leg may grow too much and be longer than the other leg.

In adults, surgery to repair the thighbone may result in one leg that is longer than the other.

Sometimes broken bones do not grow back together as expected. They may

Not grow back together (called nonunion)
Grow back together very slowly (called delayed union)
Grow back in the wrong position (called malunion)
The broken bones are not kept next to each other and are not kept from moving (meaning they are not immobilized with a cast or a splint).
The blood supply is disrupted.

Certain disorders, such as diabetes and peripheral vascular disease, and certain drugs, such as corticosteroids, can delay or interfere with healing.

When blood flow to a bone is disrupted, part of the bone may die, resulting in osteonecrosis. Certain injuries (such as scaphoid wrist fractures and hip fractures in which the broken bones are out of place) are more likely to cause osteonecrosis.

Key points about fractures

A fracture is a partial or complete break in the bone. There are many different types of fractures.
Bone fractures are often caused by falls, trauma, or as a result of a direct blow or kick to the body. Overuse or repetitive motions can cause stress fractures. Fractures can also be caused by diseases that weaken the bone. These include osteoporosis or cancer in the bones.
The main goal of treatment is to put the pieces of bone back in place so the bone can heal. This can be done with a splint, cast, surgery, or traction.
You should see a healthcare provider any time you think you may have a broken bone.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

Know the reason for your visit and what you want to happen.
Before your visit, write down questions you want to be answered.
Bring someone with you to help you ask questions and remember what your provider tells you.
At the visit, write down the name of a new diagnosis, and any new medicines, treatments, or tests. Also, write down any new instructions your provider gives you.
Know why a new medicine or treatment is prescribed, and how it will help you. Also, know what the side effects are.
Ask if your condition can be treated in other ways.
Know why a test or procedure is recommended and what the results could mean.
Know what to expect if you do not take the medicine or have the test or procedure.
If you have a follow-up appointment, write down the date, time, and purpose for that visit.
Know how you can contact your provider if you have questions.

References

Fracture of Bones