A fracture is a break in a bone. Most fractures result from a single, significant force applied to normal bone. Show
In addition to fractures, musculoskeletal injuries include
Musculoskeletal injuries are common and vary greatly in mechanism, severity, and treatment. The extremities, spine, and pelvis can all be affected. Some fractures are discussed elsewhere in THE MANUAL:
Musculoskeletal injuries may occur in isolation or as part of multisystem trauma (see Approach to the Trauma Patient Approach to the Trauma Patient Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than... read more ). Most musculoskeletal injuries result from blunt trauma, but penetrating trauma can also damage musculoskeletal structures. Pathophysiology of FracturesFractures may be either
Pathologic fractures occur when mild or minimal force fractures an area of bone weakened by a disorder (eg, osteoporosis, cancer, infection, bone cyst). When the disorder is osteoporosis Osteoporosis Osteoporosis is a progressive metabolic bone disease that decreases bone mineral density (bone mass per unit volume), with deterioration of bone structure. Skeletal weakness leads to fractures... read more , these fractures are often called insufficiency or fragility fractures. Stress fractures Stress Fractures Stress fractures are small incomplete fractures that often involve the metatarsal shafts. They are caused by repetitive weight-bearing stress. Stress fractures do not usually result from a discrete... read more result from repetitive application of moderate force, as may occur in long-distance runners or in soldiers marching while carrying a heavy load. Normally, bone damaged by microtrauma from moderate force self-repairs during periods of rest, but repeated application of force to the same location predisposes to further injury and causes the microtrauma to propagate. HealingBone heals at various rates, depending on the patient's age and coexisting disorders. For example, children heal much faster than adults; disorders that impair peripheral circulation (eg, diabetes, peripheral vascular disease) slow healing. Fractures heal in 3 overlapping stages:
The inflammatory stage occurs first. A hematoma forms at the fracture site, and a small amount of bone in the distal fracture fragments is resorbed. If a fracture line is not evident initially (eg, in some nondisplaced fractures), one typically becomes evident about 1 week after the injury as this small amount of bone is resorbed. During the reparative stage, a callus is formed. New blood vessels develop, enabling cartilage to form across the fracture line. Immobilization (eg, casting) is needed during the first 2 stages to allow new blood vessels to grow. The reparative phase ends with clinical union of the fracture (ie, when there is no pain at fracture site, the injured extremity can be used without pain, and clinical examination detects no bone movement). In the remodeling stage, the callus, which was originally cartilaginous, becomes ossified, and the bone is broken down and rebuilt (remodeled). During this stage, patients should be instructed to gradually resume moving the injured part normally, including putting load-bearing stress on it. ComplicationsSerious complications of fractures are unusual but may threaten life or limb viability or cause permanent limb dysfunction. Risk of complications is high with open fractures (which predispose to infection) and with fractures that disrupt blood vessels, tissue perfusion, and/or nerves. Closed fractures that do not involve blood vessels or nerves, particularly those that are quickly reduced, are least likely to result in serious complications. Acute complications (associated injuries) include the following:
Long-term complications of fractures include the following:
Complications references
Evaluation of Fractures
In the emergency department, if the mechanism of injury suggests potentially severe or multiple injuries (eg, a high-speed motor vehicle crash or fall from a height), patients are first evaluated from head to toe for serious injuries to all organ systems and, if needed, are resuscitated (see Approach to the Trauma Patient Approach to the Trauma Patient Injury is the number one cause of death for people aged 1 to 44. In the US, there were 278,345 trauma deaths in 2020, about 70% of which were accidental. Of intentional injury deaths, more than... read more ). Patients, especially those with pelvic or femoral fractures, are evaluated for hemorrhagic shock due to occult blood loss. If a limb is injured, it is immediately evaluated for open wounds and symptoms or signs of neurovascular injury (numbness, paresis, poor perfusion) and compartment syndrome (eg, pain out of proportion to injuries, pallor, paresthesias, coolness, pulselessness). Clinicians may suspect fractures based on symptoms and results of the physical examination, but imaging (usually x-rays) is required to confirm the diagnosis. Patients should be checked for ligament, tendon, and muscle injuries as well as fractures. The presence of a fracture can limit this part of this evaluation (eg, stress testing cannot be done because pain is initially prohibitive). The joint above and below the injury should also be examined, because concomitant injuries and referred pain are common. HistoryThe mechanism (eg, the direction and magnitude of force) may suggest the type of injury. However, many patients do not remember or cannot describe the exact mechanism. A perceived snap or pop at the time of injury may signal a fracture (or a ligament or tendon injury). Fractures and serious ligamentous injuries usually cause immediate pain; pain that begins hours to days after the injury suggests minor injury. Pain that is out of proportion to the apparent severity of the injury or that steadily worsens in the first hours to days immediately after injury suggests compartment syndrome Compartment Syndrome Compartment syndrome is increased tissue pressure within a closed fascial space, resulting in tissue ischemia. The earliest symptom is pain out of proportion to the severity of injury. Diagnosis... read more or ischemia. Physical examinationExamination includes
If muscle spasm and pain limit physical examination (particularly stress testing), examination is sometimes easier after the patient is given a systemic analgesic or local anesthetic. Or the fracture can be immobilized until muscle spasm subsides, usually for a few days, and then the patient can be reexamined. Certain findings may indicate a fracture or another musculoskeletal injury. Deformity may indicate a fracture, but it may also indicate dislocation or subluxation (partial separation of bones in a joint). Swelling commonly indicates a fracture or other significant musculoskeletal injury but may require several hours to develop. If no swelling occurs within this time, fracture is unlikely. With some fractures (eg, buckle fractures, small fractures without displacement), swelling may be subtle, but it is rarely absent. Tenderness accompanies nearly all musculoskeletal injuries, and for many patients, palpation anywhere around the injured area causes discomfort. However, a noticeable increase in tenderness in one localized area (point tenderness) suggests a fracture. A defect may be palpable in the affected bone in some fractures. Crepitus (a characteristic palpable and/or audible grinding produced when the joint is moved) may be a sign of fracture. If a wound is near a fracture, the fracture is assumed to be open. Open fractures can be classified using the Gustilo-Anderson system:
Higher grades indicate a higher risk of infection and later osteomyelitis; however, interobserver reliability using this system is not high (often about 60%), and certain aspects can be best assessed intraoperatively. Attention to certain areas during examination can help detect commonly missed injuries (see ). Table If physical examination is normal in a joint that patients identify as painful, the cause may be referred pain. For example, patients with a slipped capital femoral epiphysis Slipped Capital Femoral Epiphysis (SCFE) Slipped capital femoral epiphysis is movement of the femoral neck upward and forward on the femoral epiphysis. Diagnosis is with x-rays of both hips; sometimes other imaging is needed. Treatment... read more (or less often hip fracture Hip Fractures Hip fractures may occur in the head, neck, or area between or below the trochanters (prominences) of the femur. These fractures are most common among older patients, particularly those with... read more ) may feel pain in their knee. ImagingNot all suspected fractures require imaging. Some fractures are minor and are treated similarly to soft-tissue injuries. For example, most injuries of toes 2 through 5 and many fingertip injuries are treated symptomatically whether a fracture is present or not; thus, x-rays are not needed. In many patients with ankle sprains, the probability of finding a fracture that would require a change in treatment is acceptably low, so x-rays are not needed. For ankle sprains, generally accepted criteria for obtaining x-rays ( ) can help limit x-rays to patients that are more likely to have a fracture requiring specific treatment. If imaging is needed, plain x-rays are done first. Plain x-rays show primarily bone (and joint effusion secondary to bleeding or occult fracture) and thus are useful for diagnosing fractures. They should include at least 2 views taken in different planes (usually anteroposterior and lateral views). Additional views (eg, oblique) may be done when
For lateral views of digits, the digit of interest should be separated from the others. MRI or CT can be used if
For example, if findings after a fall suggest hip fracture but x-rays are normal, MRI should be done to check for an occult hip fracture. Other tests may be done to check for related injuries:
Fracture descriptionA fracture’s appearance on x-rays can be described relatively precisely using the following terms:
Terms for fracture location include
Common types of fracture linesTransverse fractures are perpendicular to the long axis of a bone. Oblique fractures occur at an angle. Spiral fractures result from a rotatory mechanism; on x-rays, they are differentiated from oblique fractures by a component parallel to the long axis of bone in at least 1 view. Comminuted fractures have > 2 bone fragments. Comminuted fractures include segmental fractures (2 separate breaks in a bone). Avulsion fractures are caused by a tendon dislodging a bone fragment. In impacted fractures, bone fragments are driven into each other, shortening the bone; these fractures may be visible as a focal abnormal density in trabeculae or irregularities in bone cortex. Torus fractures (buckling of the bone cortex) and greenstick fractures (cracks in only 1 side of the cortex) are childhood fractures. Different Types of Fractures Transverse Fracture of the Tibial ShaftThis transverse fracture affects the midshaft of the tibia. Image courtesy of Danielle Campagne, MD. Torus Fracture of the FingerTorus fractures may be visible only as subtle irregularities in bone cortex. PHOTOSTOCK-ISRAEL/SCIENCE PHOTO LIBRARY Torus Wrist FractureThis torus fracture of the distal radius is visible only as a slight irregularity of the bone cortex. LIVING ART ENTERPRISES, LLC/SCIENCE PHOTO LIBRARY Ankle Fracture of Both MalleoliThis ankle fracture involves the medial malleolus (of the tibia) and lateral malleolus (of the fibula). SCIENCE PHOTO LIBRARY Greenstick Fracture of the Distal RadiusThis x-ray shows a greenstick fracture of the distal radius, visible as a discontinuity (step-off) in the radial aspect of the cortex (arrow). ZEPHYR/SCIENCE PHOTO LIBRARY Midshaft Femur Fracture (1)This image shows a comminuted, angulated, and shortened midshaft femur fracture. Image courtesy of Danielle Campagne, MD. Midshaft Femur Fracture (2)This lateral femur x-ray shows a midshaft femur fracture with soft tissue air and retained metallic density foreign bodies. Image courtesy of Danielle Campagne, MD. Spatial relationship between fracture fragmentsDistraction, displacement, angulation, or shortening (overriding) may occur. Distraction is separation in the longitudinal axis. Displacement is the degree to which the fractured ends are out of alignment with each other; it is described in millimeters or bone width percentage. Angulation is the angle of the distal fragment measured from the proximal fragment. Displacement and angulation may occur in the ventral-dorsal plane, lateral-medial plane, or both. Treatment of Fractures
Initial treatmentSerious associated problems, if present, are treated first. is treated immediately. Injuries to arteries are surgically repaired unless they affect only small arteries with good collateral circulation. Compartment syndrome Compartment Syndrome Compartment syndrome is increased tissue pressure within a closed fascial space, resulting in tissue ischemia. The earliest symptom is pain out of proportion to the severity of injury. Diagnosis... read more is treated. Severed nerves are surgically repaired; for neuropraxia and axonotmesis, initial treatment is usually observation, supportive measures, and sometimes physical therapy. Suspected open fractures require sterile wound dressings, tetanus prophylaxis, broad-spectrum antibiotics (eg, a 2nd-generation cephalosporin plus an aminoglycoside), and surgery to irrigate and debride them (and thus prevent infection). To minimize the risk of infection in open fractures, IV antibiotics should be given early, for example, within 1 hour of emergency department presentation ( ). Most moderate and severe fractures, particularly grossly unstable ones, are immobilized immediately by splinting (immobilization with a nonrigid or noncircumferential device) to decrease pain and to prevent further injury to soft tissues by unstable fractures. In patients with long-bone fractures, splinting may prevent fat embolism. Pain is treated as soon as possible, typically with or regional nerve blocks. If a patient has an isolated extremity fracture and compartment syndrome is not suspected, regional anesthesia may be used; this approach can help minimize the use of opioids and provides greater pain relief than opioids alone ( ). After initial treatment, fractures are reduced, immobilized, and treated symptomatically as indicated. ReductionRotational malalignment or significant angulation or displacement of fractures is typically treated with reduction (realignment of bones or bone fragments by manipulation), which usually requires analgesia and/or sedation. Exceptions include some fractures in children in whom remodeling over time can correct significant deformities. Closed reduction (by manipulation, without skin incision) is done when possible. If closed reduction is not possible, open reduction (with skin incision) is done; anesthesia is required. Closed reduction of fractures is usually maintained by casting, but some fractures require only a splint or sling. Open reduction of fractures is usually maintained by various surgical hardware, external and/or internal. In open reduction with internal fixation (ORIF), fracture fragments are aligned and held in place using a combination of pins, screws, and plates. ORIF is usually indicated when
PRICEPRICE (protection, rest, ice, compression, elevation) may be beneficial. Protection helps prevent further injury. It may involve limiting the use of an injured part, applying a splint or cast, or using crutches. Rest may prevent further injury and speed healing. Ice and compression may minimize swelling and pain. Ice is enclosed in a plastic bag or towel and applied intermittently during the first 24 to 48 hours (for 15 to 20 minutes, as often as possible). Injuries can be compressed by a splint, an elastic bandage, or, for certain injuries likely to cause severe swelling, a Jones compression dressing. The Jones dressing is 4 layers; layers 1 (the innermost) and 3 are cotton batting, and layers 2 and 4 are elastic bandages. Elevating the injured limb above the heart for the first 2 days in a position that provides an uninterrupted downward path; such a position allows gravity to help drain edema fluid and minimize swelling. After 48 hours, periodic application of warmth (eg, a heating pad) for 15 to 20 minutes may relieve pain and speed healing. ImmobilizationImmobilization decreases pain and facilitates healing by preventing further injury and keeping the fracture ends in alignment. Joints proximal and distal to the injury should be immobilized. Most fractures are immobilized for weeks in a cast (a rigid, circumferential device). A few rapidly healing, stable fractures (eg, buckle wrist fractures in children) are not casted; early mobilization has the best results. A cast is usually used for fractures that require weeks of immobilization. Rarely, swelling under a cast is severe enough to contribute to compartment syndrome Compartment Syndrome Compartment syndrome is increased tissue pressure within a closed fascial space, resulting in tissue ischemia. The earliest symptom is pain out of proportion to the severity of injury. Diagnosis... read more . If clinicians suspect severe swelling under a cast, the cast (and all padding) is cut open from end to end medially and laterally (bivalved). Patients with casts should be given written instructions, including the following:
Good hygiene is important. A splint (see figure ) can be used to immobilize some stable injuries, including some suspected but unproven fractures and rapidly healing fractures that require immobilization for several days or less. A splint is noncircumferential; thus, it enables patients to apply ice and to move more than a cast does. Also, it allows for some swelling, so it does not contribute to compartment syndrome. Some injuries that ultimately require casting are immobilized initially with a splint until most of the swelling resolves. How To Apply Immobilizing Devices How To Apply a Posterior Ankle SplintHow To Apply a Knee ImmobilizerHow To Apply Plaster Splints© Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. How To Apply Fiberglass Splints© Elsevier Inc. All Rights Reserved. This video is for personal informational use. Users are prohibited from copying, reproducing, licensing, subscribing, selling, leasing or distributing this video. Joint immobilization as acute treatment: Some commonly used techniquesA sling provides some degree of support and comfort and limits mobility; it can be useful for certain fractures (eg, minimally displaced clavicle fractures, certain proximal humerus fractures), particularly if complete immobilization is undesirable (eg, for shoulder injuries, which, if completely immobilized, can rapidly lead to adhesive capsulitis [frozen shoulder]). How To Remove a Cast VIDEO A swathe (a piece of cloth or a strap) may be used with a sling to prevent the arm from swinging outward, especially at night. The swathe is wrapped around the back and over the injured part. A swathe is sometimes used with a sling to immobilize one-part proximal humeral fractures. , which is occasionally required for fractures (eg, some vertebral or pelvic fractures), can cause problems (eg, deep venous thrombosis, urinary tract infection, muscle deconditioning). Prolonged immobilization (> 3 to 4 weeks for young adults) of a joint can cause stiffness, contractures, and muscle atrophy and is usually not recommended. These complications may develop rapidly and may be permanent, particularly in older people. Some rapidly healing injuries are best treated with resumption of active motion within the first few days or weeks; such early mobilization may minimize contractures and muscle atrophy, thus accelerating functional recovery. Splints and casts should immobilize joints in positions that optimize the likelihood of return of full function (eg, immobilization of the metacarpophalangeal [MCP] joints should position the MCP joints in flexion to maintain lengthening of the hand tendons). Physical therapists can advise patients about what they can do during immobilization to maintain as much function as possible. After immobilization, physical therapists can provide patients with exercises to improve range of motion and muscle strength, strengthen and stabilize the injured joint, and thus help prevent recurrence and long-term impairment. Other proceduresJoint replacement (arthroplasty) may be needed, usually when fractures severely damage the upper end of the femur or the humerus. Bone grafting may be done immediately if the gap between fragments of bone is too large. It may be done later if healing is delayed (delayed union) or does not occur (nonunion). Treatment references
Geriatrics Essentials: FracturesOlder people are predisposed to fractures because of the following:
Age-related fractures include fractures of the distal radius, proximal humerus, pelvis, proximal femur, and vertebrae. For older patients, the goal of treatment is rapid return to activities of daily living rather than restoration of perfect limb alignment and length. Because immobility (joint immobilization or bed rest) is more likely to have adverse effects in older patients, use of open reduction with internal fixation (ORIF) to treat fractures is increasing. Early mobilization (made possible by ORIF) and physical therapy are essential to recovery of function. Coexisting disorders (eg, arthritis) can interfere with recovery. Key Points
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