A fracture is a complete or incomplete break in a bone resulting from the application of excessive force. An injury may be classified as a fracture-dislocation when a fracture involves the bony structures of any joint with associated dislocation of the same joint.
Description
Fractures usually result from traumatic injury to a bone, causing the continuity of bone tissues or bony cartilage to be disrupted or broken. Fracture classifications include simple, compound, incomplete, and complete. Simple fractures (more recently termed closed fractures) are not obvious on the surface, as the skin has not been broken and remains intact. Compound fractures (now commonly referred to as open fractures) break the skin, exposing bone and causing additional soft tissue injury and possible infection. Single and multiple fractures refer to the number of breaks in the same bone. Fractures are termed complete if the break is completely through the bone, and described as incomplete or "greenstick" if the fracture occurs partly across a bone shaft. This latter type of fracture is often the result of bending or crushing forces applied to a bone.
Fractures are also named by the specific portion of the bone involved and the nature of the break. Identification of a fracture line can further classify fractures. Types include linear, oblique, transverse, longitudinal, and spiral fractures. Fractures can be further subdivided by the positions of bony fragments and are described as comminuted, non-displaced, impacted, overriding, angulated, displaced, avulsed, and segmental.
Fracture lines identification
Linear fractures have a break that runs parallel to the bone's main axis or in the direction of the bone's shaft. For example, a linear fracture of the arm bone could
extend the entire length of the bone. Oblique and transverse fractures differ in that an oblique fracture crosses a bone at approximately a 45° angle to the bone's axis. In contrast, a transverse fracture crosses a bone's axis at a 90° angle. A longitudinal fracture is similar to a linear fracture. Its fracture line extends along the shaft but is more irregular in shape and does not run parallel to the bone's axis. Spiral fractures are described as crossing a bone at an oblique angle, creating a spiral pattern. This type of break usually occurs in the long bones of the body such as the upper arm bone (humerus) or the thigh bone (femur).
Bony fragment position identification
Comminuted fractures have two or more fragments broken into small pieces, in addition to the upper and lower halves of a fractured bone. Fragments of bone that maintain their normal alignment following a fracture are described as being non-displaced. An impacted fracture is characterized as a bone fragment forced into or onto another fragment, resulting from a compressive force. Overriding is a term used to describe bony fragments that overlap and shorten the total length of a bone. Angulated fragments result in pieces of bone being at angles to each other. A displaced bony fragment occurs from disruption of normal bone alignment with deformity of these segments separate from one another. An avulsed fragment occurs when bone fragments are pulled from their normal position by forceful muscle contractions or resistance from ligaments. Segmental fragmented positioning occurs if fractures in two adjacent areas occur, leaving an isolated central segment. An example of segmental alignment occurs when the arm bone fractures in two separate places, with displacement of the middle section of bone.
Causes and symptoms
Individuals with high activity levels appear to have a greater risk for fractures. This group includes children and athletes participating in contact sports. Because of an increase in bone brittleness with aging, elderly persons are also included in this high-risk population. It has been recognized that up to the age of 50, more men suffer from fractures than women due to occupational hazards. However, after the age of 50, more women suffer fractures than men. Specific diseases causing an increased risk for fractures include Paget's disease, rickets, osteogenesis imperfecta, osteoporosis, and prolonged disuse of a nonfunctional body part such as after a stroke.
Symptoms of fractures usually begin with pain and swelling at the involved site. There may also be a great deal of tenderness in the area near the fracture. The skin in the area may be pale and an obvious deformity may be present. In more severe cases, there may be a loss of pulse below the fracture site (such as in the extremities), accompanied by numbness, tingling, or paralysis below the fracture. An open or compound fracture is often accompanied by bleeding or bruising. If a leg is fractured, weakness will usually accompany the injury, causing difficulty with weight bearing.
Diagnosis
Diagnosis begins immediately with an individual's own observation of symptoms. A thorough medical history and physical exam completed by a physician or advanced practice nurse often provides enough information to determine if further testing is necessary. An x ray of the injured area is the most common test used to determine the presence of a bone fracture and its associated displacement. However, it is important to note that not all fractures are apparent on an initial x ray. Rib fractures are often difficult to diagnose and may require several views at different angles to see any fracture lines. If a fracture is open and occurs in conjunction with soft tissue injury, further laboratory studies are often conducted to determine if blood loss has occurred.
In the event of exercise-related stress fractures (micro-fractures due to excessive stress), a tuning fork can provide a simple, inexpensive test. The tuning fork is a metal instrument with a stem and two prongs that vibrate when struck. If an individual has increased pain when the tuning fork is placed on a bone, such as the lower leg bone or shinbone, the likelihood of a stress fracture is high. Bone scans are also helpful in detecting stress fractures. In this diagnostic procedure, a radioactive tracer is injected into the blood stream and images are taken of specific areas or the entire skeleton.
Treatment
Fracture treatment depends on the type of fracture, its severity, and the individual's age and general health. The first priority in treating any fracture is to address the entire medical status of an individual. If an open fracture is accompanied by serious soft tissue injury, it may be necessary to control bleeding and the shock that can accompany loss of blood.
First aid is the appropriate initial treatment in emergency situations. It includes proper splinting, control of blood loss, and monitoring vital signs such as breathing and circulation.
Immobilization
Immobilization of a fracture site can be done internally or externally. The primary goal of immobilization is to maintain the realignment of a bone long enough for healing to start and progress. Immobilization by external fixation uses splints, casts, or braces. This may be the primary and only procedure for fracture treatment. Splinting to immobilize a fracture can be done with or without traction. In emergency situations, splinting is a useful form of fracture management if the injured individual must be moved by someone other than a trained medical professional. Splinting should be done without causing additional pain and without moving the bone segments. In a clinical environment, plaster of Paris casts are used for immobilization. Braces are also useful, as they often allow movement above and below a fracture site. Treatments for stress fractures include rest and decreasing or stopping any activity that causes or increases pain.
Fracture reduction
Fracture reductions are either closed or open. Closed reduction refers to realigning bones without breaking the skin. It is accomplished using manipulation and/or traction and is commonly done with some kind of anesthetic. Open reduction primarily refers to surgery that is performed to realign bones or fragments. Fractures with little or no displacement may not require any form of reduction.
Traction is used to help reposition a broken bone. It works by applying pressure to restore proper alignment. The traction device immobilizes the area and maintains realignment as the bone heals. A fractured bone is immobilized by applying opposing forces at both ends of an injured area, using an equal amount of traction and countertraction. Weights provide the traction pull needed, or the pull is achieved by positioning the individual's body weight. Traction is a form of closed reduction and is sometimes used as an alternative to surgery. Since it restricts movement of an affected limb or body part, it may confine a person to bed rest for an extended period of time.
A person may need open reduction if there is an open, severe, or comminuted fracture. This procedure allows a physician to examine and surgically correct associated soft tissue damage while reducing the fracture and, if necessary, applying internal or external devices. Internal fixation is a surgical procedure that is required when a fracture cannot be reduced by closed fracture methods. Internal fixation devices include plates, nails, screws, and rods. When healing is complete, the physician may or may not elect to remove these devices.
Alternative treatment
In addition to the importance of calcium for strong bones, many alternative treatment approaches advocate mineral supplements to help build and maintain a healthy, resilient skeleton. Some physical therapists use electrostimulation over a fractured site to promote healing. Chinese traditional medicine may be helpful by working to reconnect chi through the meridian lines along the line of a fracture. Homeopathy can enhance the body's healing process. Two particularly useful homeopathic remedies are arnica (Arnica montana) and symphytum (Symphytum officinalis). If possible, applying contrast hydrotherapy to an extremity (e.g., a hand or foot) of a fractured area can assist healing by enhancing circulation.
Prognosis
Fractures can normally be cured with proper first aid and appropriate aftercare. If determined necessary, the fractured site should be manipulated, realigned, and immobilized as soon as possible. Realignment has been shown to be much more difficult after six hours. Healing time varies from person to person, with the elderly generally needing more time to heal completely. A non-union fracture may result when a fracture does not heal, such as in the case of an elderly person or an individual with medical complications. Recovery is complete when there is no bone motion at the fracture site, and x rays indicate complete healing.
Health care team roles
When treating most fractures, an orthopedic surgeon is the head of the health care team. These physicians have specialized training in bones. They are responsible for reducing, realigning, and immobilizing fractured bones. In the absence of an orthopedic surgeon, a general surgeon or a family practitioner may treat simple, closed fractures. Emergency medical service providers may render immediate first aid to persons with fractures. After fracture reduction and healing have occurred, physical therapists may assist in returning injured body parts to their normal levels of function.
Prevention
Adequate calcium intake is necessary for strong bones and can help decrease the risk of fractures. People
who do not get enough calcium in their diets can take a calcium supplement. Exercise can help strengthen bones by increasing bone density, thereby decreasing the risk of fractures from falls. A University of Southern California study reported that older people who exercised one or more hours per day had approximately half the incidence of hip fractures as those who exercised fewer than 30 minutes per day or not at all.
Fractures can be prevented if safety measures are taken seriously. These measures include using seat belts in cars and encouraging children to wear protective sports gear. Estrogen replacement for women past the age of 50 has been shown to help prevent osteoporosis and the fractures that may result from this condition. In one study, elderly women on estrogen replacement therapy demonstrated a lower risk of hip fractures when compared to similar women not on estrogen replacement therapy.
KEY TERMS
Avulsion facture—A fracture caused by the tearing away of a fragment of bone where a strong ligament or tendon attachment forcibly pulls the fragment away from the bone tissue.>
Axis—A line that passes through the center of the body or body part.
Comminuted fracture—A fracture in which there are several breaks in a bone, creating numerous fragments.
Contrast hydrotherapy—A series of hot and cold water applications. A hot compress (as hot as an individual can tolerate) is applied for three minutes followed by an ice cold compress for 30 seconds. These applications are repeated three times each and ending with the cold compress. Osteogenesis imperfecta—A genetic disorder involving defective development of connective tissues, characterized by brittle and fragile bones that are easily fractured by the slightest trauma. Osteoporosis—Literally meaning "porous bones," this condition occurs when bones lose an excessive amount of their protein and mineral content, particularly calcium. Over time, bone mass and strength are reduced leading to increased risk of fractures.
Paget's disease—A common disease of bone of unknown cause, usually affecting middle-aged and elderly people, characterized by excessive bone destruction and unorganized bone repair. Reduction—The restoration of a body part to its original position after displacement, such as the reduction of a fractured bone by bringing ends or fragments back into original alignment. The use of local or general anesthesia usually accompanies a fracture reduction. If performed by outside manipulation only, the reduction is described as closed; if surgery is necessary, it is described as open. Rickets—A condition caused by the deficiency of vitamin D, calcium, and usually phosphorus, seen primarily in infancy and childhood, and characterized by abnormal bone formation.
Traction—The process of placing a bone, limb, or group of muscles under tension by applying weights and pulleys. The goal is to realign or immobilize the part or to relieve pressure on that particular area to promote healing and restore function.
BOOKS
Burr, David B. Musculoskeletal Fatigue and Stress Fracture. Boca Raton, FL: CRC Press, 2001.
Jupiter, J. Fractures and Dislocations of the Hand. St. Louis, MO: Mosby, 2001.
Moehring, H. David and Greenspan, Adam. Fractures: Diagnosis and Treatment. New York: McGraw Hill, 2000.
Ogden, John A. Skeletal Injury in the Child. New York: Springer Verlag, 2000.
Schenck, Robert C. and Barnes, Ronnie P. Athletic Training and Sports Medicine, 3rd ed. Chicago, IL: American Academy of Orthopaedic Surgery, 1999.
Wiss, Donald A., and Williams, Christopher B. Fractures. Baltimore, MD: Williams and Wilkins, 1998.
PERIODICALS
Lesho, Emil P. "Tuning Fork Test Finds Fractures." Military Medicine 162 (1997): 802-803.
ORGANIZATIONS
American Academy of Orthopaedic Surgeons. 6300 North River Road, Rosemont, IL 60018-4262. (847) 823-7186 or (800) 346-2267. Fax: (847) 823-8125. <http://orthoinfo.aaos.org/>.
American College of Sports Medicine. P.O. Box 1440, Indianapolis, IN 46206-1440. 401 W. Michigan St., Indianapolis, IN 46202. (317) 637-9200, Fax: (317) 634-7817.
Children's Orthopedics of Atlanta. <http://www.childrensortho.com/fractures.htm>.
