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Fractures

Classification

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Definition

Fracture (from Latin fractūra) a breakin the continuity of a bone, a brokenbone. A fracture is present whenthere is loss of continuity in thesubstance of a bone.

 The term covers all bony disruptions,ranging from the situation when (1) abone is broken into many fragments(multifragmentary or comminuted

fracture) to (2) hairline and evenmicroscopic fractures.

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Fractures are caused by the

application of stresseswhich exceed the limits ofstrength of a bone.

iolence is the commonestcause.

!n the case of directviolence, a bone may befractured by being struck bya moving or falling ob"ect.

ery fre#uently, fractures

result from indirectviolence. A twisting orbending stress is applied toa bone, and this results inits fracture at somedistance from theapplication of the causalforce.

Cau ses of f ract ure

Indirect

violence

Indirect

violence

Directviolenc

e

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$ometimes fracture may occur

in an abnormal or diseasedbone. !f the osseousabnormality reduces thestrength of the bone thenthe force re#uired toproduce fracture is reduced,

and may even becometrivial. %or example, asecondary tumor deposit orsevere osteoporosis maylead to a pathologicalfracture of the bone.

Cau ses of f ract ure

Anteroposterior radiograph at initial evaluation ofa fracture through a unicameral (simple) bonecyst in the proximal end of the humerus of a &'

year'old girl

Bonecyst 

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Fatigue fractures (stress

fractures): $tresses,repeated with excessivefre#uency to a bone, mayresult in fracture. Thismechanism is oftencompared with fatigue inmetals which break after

repeated bending beyondtheir elastic limit. Thecommonest of thesefractures involves thesecond metatarsal ' themarch fracture (so'called

because of its fre#uency inarmy recruits).

Stress fractures aregenerally hairline in patternand are often not diagnosedwith certainty until there issubperiosteal callusformation, or increaseddensit at the fracture site

Cau ses of f ract ure

*ealed fatigue fracturethrough the secondmetatarsal bone + a

march fracture-

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Open and closed fractures

Closed fracture (a) the bone isbroken, but there is no

external wound. A fracture notcommunicating with theexternal environment, theoverlying skin are intact

Open fracture A fracture withbreak in the overlying skin andsoft'tissues, leading to thefracture.

A fracture in which the skin hasbeen penetrated by a bonefragment from inside isreferred to as compound fromwithin out  (b) 

%ractures opened from without in (c), the so'called externalcompounding This type ofin"ury is caused by directviolence/ the causal forcebreaks the skin and fractures

the underlying bone.

The risks of infection are much less in open from within out  

fractures than in those from without in

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Simple fractures

Simple transverse fractures (a)

 Transverse fractures run either at rightangles to the long axis of a bone (0), orwith an obli#uity of less than 12.

 The inherent stability of this type offracture (illustrated by the model onthe right) reduces the risks ofshortening and displacement.

The term 'simple‘, used to describe this fractures, means that the fracture runs

circumferentially round the bone with the formation of only two main fragments

!n an oblique fracture (0) the fractureruns at an obli#ue angle of 12 or more(3). $uch fractures may be caused by(a) direct or (b) indirect violence. !n

simple spiral fractures (4) the line ofthe fracture curves round the bone in aspiral.

Simple spiral fractures result fromindirect violence, applied to the boneby twisting (torsional) forces (t).

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Multifragmental fractures

In multifragmentary (comminuted)fractures there are more than twofragments.

 The spiral edge fracture (0) isproduced by torsional forces (t),

And the bending edge fracture (4)by direct (a) or indirect (b) violence.

 The fragment (5) is often called abutterfly fragment (because of itsshape).

6ith greater violence, a fragmented

(comminuted) edge fracture ()results.

 Their characteristic is that after reductionthere is still bony contact beteenthe main fragments (7)).

12

34

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Multifragmental fractures

!n multifragmentary comple!  fractures there is no contactbeteen the main fragments afterreduction.

!n comple! spiral fractures (0) thereare two or more spiral elements/

!n comple! segmental fractures(sometimes called double fractures) (4)there is at least one #uite separatecomplete bone fragment ($).

!n comple! irregular fractures ()the bone lying between the mainelements is split into many irregularfragments.

12 3

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 Avulsion fractures

 "vulsion fractures (a) An avulsionfracture may be produced by a sudden

muscle contraction, the muscle pullingoff the portion of bone to which it isattached.

8ommon examples include

(0) 5ase of fifth metatarsal (peroneusbrevis).

(4) Tibial tuberosity (#uadriceps).() 9pper pole of patella (#uadriceps).

(7) Lesser trochanter (iliopsoas).

 "vulsion fractures may also result fromtraction on a ligamentous or capsular

attachment (1) an abduction force mayavulse the ulnar collateral ligamentattachment, with spontaneous reduction.Little subluxation (2) is common with thisin"ury (gamekeepers thumb).

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Impacted and compression fractures

Impacted fractures A fracture isimpacted when one fragment is driveninto the other. 8ancellous bone isusually involved and union is oftenrapid. These fractures are more stabilethan other. :isplacement will occur if

the fracture is sub"ected to deformingforces.

#ompression (or crush) fractures 8rushfractures occur in cancellous bone whichis compressed beyond the limits oftolerance. 8ommon sites are (0) thevertebral bodies (as a result of flexionin"uries) and (4) the heels (following fallsfrom a height).

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Depressed and stellate fracture

Depressed fracture :epressed fracturesoccur when a sharply localised blowdepresses a segment of cortical bonebelow the level of the surrounding bone.Although common in skull fractures, thispattern is only rarely found in the limbs,where the tibia in the upper third is

probably most fre#uently affected.*ealing is rapid/ complications aredependent on the site.

Stellate fracture This is a fracture with

numerous fissures radiating from centralpoint of in"ury. This occurs in flat bonesof the skull and in patella, where thefracture lines run in various directionsfrom one point.

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Describing the level of a fracture

 The anatomical divisions of a long boneinclude the epiphysis (;), epiphyseal

plate (; fracture of the tibial diaphysis/5 > fracture of the femoral neck/

8 > fracture of the greater trochanter/

% > supracondylar fracture of the femur.%or descriptive purposes a bone may be

divided into thirds. !n this way

A > fracture of the mid third of the femur/5 > fracture of the femur in the distal

third/

8 > fracture of the femur at the "unction ofthe middle and distal thirds.

: > fracture of the distal metaphysis of

radial bone.

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Fractures without displacement

!f there is no deformity then thefracture is said to be in anatomicalposition. $imilarly, if a perfectposition has been achieved after

manipulation of a fracture, it maybe described as being in anatomicalposition.

 The absence or presence ofdisplacement depends of multiplefactors as (0) the fracturing force/(4) direction of the fracture line, ()

presence of multiple fragments, (7)the muscle pull on the fracturefragments/ (?) the gravity, etc.

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Displaced fractures

There are 3 types ofdisplacement

- translation or

trans!ersedislocation"

- angulation

- a#ial rotation

- shift shortening"

T l i

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Translation

$ranslation (or transversedislocation) is present if the boneends have shifted relative to one

another. The direction of displacementis described in terms of movement ofthe distal fragment. %or example, inthese fractures of the femoral shaft atthe "unction of the middle and distalthirds, there is (0) no displacement, (4)lateral displacement, () posteriordisplacement, (7) both lateral andposterior displacement.

A l i

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 Angulation

 There are two different methods fordescribing angulation

0'st is in terms of the position of the pointof the angle,

4'nd + describing the tilt of the distal

fragment

(?) fracture of the femur with medialangulation or a fracture of the middlethird of the femur with the distalfragment tilted laterally

(&) fracture of the tibia and fibula withposterior angulation (both aremidshaft fractures).or a fracture of thetibia and fibula in the middle thirds,with the distal fragment tiltedanteriorly.

A i l t ti

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 Axial rotation

 "!ial rotation may be present whenone fragment rotates on its longaxis, with or without accompanyingdisplacement or angulation.

Sh t i

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Shortening

:isplacement of a spiral orobli#ue fracture (1) willresult in shortening.:isplacement oftransverse fractures (2)will result in shorteningonly after loss of bonycontact.

6here none of the fracture surfaces is incontact, the fracture is described as having

%no bony apposition% or being %completelyoff&ended%.

3ff'ended fractures are 0.

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r act ures n e ar t h e oint s

%ractures involving the articular surfacesof a "oint !n partial articularfractures (0) part of the "oint surfaceis involved, but the remainder is intactand solidly connected to the rest of thebone. !n complete articular

fractures (4) the articular surface iscompletely disrupted and separatedfrom the shaft.

6hen a fracture involves the articularsurfaces, any persisting irregularitymay cause secondary osteoarthritis(). $tiffness is a commoncomplication/ this may be minimisedby early mobilisation

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r act ure!disloc ations

Fracture&dislocation A fracture'dislocation is present when a "oint hasdislocated and there is in addition afracture of one of the bony componentsof the "oint. !llustrated is a fracture'dislocation of the shoulder, wherethere is an anterior dislocation with afracture of the neck of the humerus.!n"uries of this kind may be difficult toreduce and may be unstable. $tiffness

and avascular necrosis are twocommon complications.

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St able and unst able f ract ures

A stable fracture is one in which the twobones are lying in a position fromwhich they are unlikely to move. $tablefractures are often undisplaced butsome are stable even the bone ismisshapen.

$imple transverse fractures are morestabile than simple obli#ue and spiralfractures

5ut less stabile are multifragmentary and

comminuted complex fractures

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Com plic ated f ract ures

A fracture is described as complicated  ifthere is accompanying damage toma"or neighbouring structures.

b. @on'union of the tibia with union ofthe fibula.

c. =alunion with osteoarthrosis of kneeand ankle

d. !schaemia of the foot due to vasculardamage

e. 8ompartment syndrome

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Than" #ou $