Find information on different types of fractures, their causes, treatment options, and the recovery process on Meri Sehat.

Fracture

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ZAKA CLINIC GULBERG LAHORE

Saad Ullah Siddiqui

A fracture is defined as a complete or partial break in a bone that occurs when the physical force applied to the bone is stronger than the bone itself. Bones can fracture across, lengthwise, in many locations, or into numerous fragments. 
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Overview

Fractures most often result from a strong physical force. This mostly occurs due to trauma associated with a fall, sports injury, or motor vehicle crash. This disrupts the bone&#39;s structure and strength, resulting in discomfort, loss of function, and, in certain cases, bleeding and damage surrounding the location. The fracture may also result from overuse during repetitive activity, such as running or jumping. Moreover, some conditions, such as osteoporosis or cancer can weaken the bone and cause spontaneous fractures. 
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As per a Lancet study, in 2019, a total of 178 million new fracture cases were reported globally.11&nbsp;Middle-aged men and the elderly were at a particularly higher risk of fracture. This was attributed to the fact that men are more likely to work outside the home, practice sports, and engage in risky violent behaviors, all of which contribute to fractures. 
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The study also reported on the increase in incidence among women after 50 years of age, linking it to osteoporotic fractures after <a href="https://merisehat.pk/disease/menopause">menopause</a>.11&nbsp; A high percentage of the Pakistani population is deficient in calcium and vitamin D. As per a hospital-based study from Karachi, Pakistan,<a href="https://merisehat.pk/disease/vitamin-d"> vitamin D</a> insufficiency was seen in 92% of outpatients, with a female-to-male ratio of 5:1.1Moreover, <a href="https://merisehat.pk/disease/osteoporosis-80">osteoporosis </a>is a common occurrence among women aged 45 years and above, affecting 20-49.3% of postmenopausal women in Pakistan.1, 12 
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Despite the high prevalence of osteoporosis and osteopenia in the country, unfortunately, the prevalence of osteoporosis-related fractures remains unclear due to the lack of data.12&nbsp;Nor is there data on the incidence rates for hip fractures. 
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Fractures are categorized based on the alignment of the fractured bone, mechanism of injury, whether or not the skin is broken, and location.&nbsp;

They are broadly classified as open or closed. 
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Open Fracture - Also called a compound fracture, it is characterized by the broken bone piercing through the skin. A deep wound near the site of fracture can also expose the bone. However, the bone may not always be visible through the skin. 
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Closed Fracture - This is a simple fracture characterized by a broken bone that does not pierce the skin; the skin is still intact. 
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Furthermore, fractures can also be classified into complete and incomplete. A complete fracture involves a complete break in the bone. The most common type of complete fracture are: 
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Comminuted Fracture - The bone breaks or crushes into several pieces, mostly 3 or more. The bone fragments are present at the fracture site. Serious traumas, such as vehicle accidents, can result in comminuted fractures.

Displaced Fracture - As the name implies, the broken parts move and are not aligned up straight.

Non-Displaced Fracture - Although the bone is broken, the pieces are not out of alignment.

Spiral Fracture - This results from a twisting or rotational force causing a break that spirals around the bone. Sports injuries are a common cause of spiral fractures.

Segmental Fracture - A segmental fracture is characterized by the bone breaking in two places, with one piece floating and displaced.

Compression Fracture - This commonly occurs in the spine and results from the bone being crushed. It is common in osteoporotic individuals. 
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In an incomplete fracture, the bone doesn&rsquo;t break all the way through. It is more common in children as their bones are softer and are more likely to bend than break. Examples of incomplete fracture are: 
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Hairline Fracture - Also called a stress fracture, it results in a thin crack or a bruise on the bone. It is most common in athletes. Repetitive motions or overuse can tire the muscles, putting more pressure on the bone and resulting in a stress fracture.

Greenstick Fracture - This is characterized by a section of the bone being broken on one side and bent on the other. It is most common in children younger than 10 years of age.

Buckle Fracture - Also called torus or impacted fracture, it is caused by the compression of two bones that have been forced into one other. 
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Other common types of fracture include: 
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Growth Plate Fracture - This occurs at the joint, resulting in a shorter bone length.

Transverse Fracture - This happens when a bone breaks perpendicular to its length, causing a straight fracture line across the bone. They can occur in any bone in your body, but mainly affect longer bones following a trauma, such as a fall or accident.

Oblique Fracture - An oblique fracture occurs when your bone breaks at an angle, causing a diagonal fracture line across the bone. They&#39;re commonly caused by landing on your bone at an angle after a fall, or by being knocked from an angle quickly (like in a car accident).

Pathologic Fracture - The fracture results from a disease that weakens the bone, such as osteoporosis, cancer, bone cyst, or infection. Thus, making them more prone to breaking. Coughing, stepping out of a car, or leaning over can all fracture a bone that has been weakened by disease.

Avulsion Fracture - An avulsion fracture results from an injury causing the ligament or tendon to pull away a small part of the bone it is attached to. It is common in young athletes, mostly at the hip, ankles, and elbows. 
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NOTE: An open fracture is a medical emergency and requires immediate medical attention. 
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Signs and Symptoms

The symptoms mostly vary based on the location of the fracture, the severity of the injury, the patient&rsquo;s age, and the type of fracture. Severe pain and an inability to move the injured area is often the first sign. Other potential fracture symptoms include:

<ul>
	<li>Swelling, redness, and bruising in the injured area</li>
	<li>Difficulty supporting weight with the injured area</li>
	<li>Visible deformity in the injured area</li>
	<li>Bleeding in case of an open fracture</li>
	<li>Discoloration around the injured area 
	&nbsp;</li>
</ul>

In certain cases, you may see broken bone poking through your skin. And, in more severe cases, an individual may experience:

<ul>
	<li>Dizziness</li>
	<li>Faintness</li>
	<li>Nausea 
	&nbsp;</li>
</ul>
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Causes

Trauma is often the most common cause of bone fractures. A fall, road traffic accident, or a direct blow to the body puts great force on the bone, causing it to break. However, fractures can also occur without trauma. Repetitive motion and overuse of muscles can lead to stress fractures. Moreover, diseases, such as osteoporosis or bone cancers can weaken bones and increase the risk of fractures. 
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Diagnosis

If a doctor suspects a broken bone, they will take a complete history and conduct a physical examination. During a physical examination, the site of injury is assessed for swelling, bruising, tenderness, crepitus, and deformity. Moreover, the following tests may be performed to diagnose the fracture. 
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<ul>
	<li>X-ray: The imaging scan allows doctors to visualize the internal tissues, bones, and organs in the body. X-rays are the most common method for diagnosing fractures. They can also help assess the location and type of fracture. 
	&nbsp;</li>
	<li>MRI: An MRI scan provides a detailed image of the internal structures, such as the cartilage and ligaments surrounding the bones. It can also help detect an occult hip fracture. 
	&nbsp;</li>
	<li>CT Scan: This is more detailed than an X-ray and helps assess the bones, joints, and tissues for damage, lesions, fractures, or other problems. It is typically used when an X-ray is inconclusive in determining a fracture. Skull fractures are often diagnosed using CT scans. 
	&nbsp;</li>
	<li>Bone Scan: A bone scan is used by healthcare practitioners to detect fractures that are not visible on an X-ray. This scan takes longer (often two visits four hours apart), but it can aid in the detection of certain fractures. 
	&nbsp;</li>
</ul>
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Treatment

Doctors often use grading systems to determine treatment and prevent any complications of fractures. The Gustilo-Anderson approach is used to classify open fractures. 
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<ul>
	<li>Grade I: Less than 1 cm wound with little contamination, comminution, and soft-tissue injury.</li>
	<li>Grade II: Wound is more than 1cm in diameter with a significant soft-tissue injury and little periosteal peeling.</li>
	<li>Grade III-A: There is severe soft-tissue injury and significant contamination, with adequate soft-tissue coverage.</li>
	<li>Grade III-B: Extensive soft-tissue damage with periosteal stripping and bone exposure. Moreover, there&rsquo;s major wound contamination.</li>
	<li>Grade III-C: Open fracture with arterial injury requiring repair. 
	&nbsp;</li>
</ul>

The aim of treatment is to re-align the broken fragments, reduce pain, heal the bone, prevent complications, and restore the functioning of the fractured bone.

An open fracture necessitates a different treatment than a closed fracture, which does not have an open wound. This is because germs from the dirt and other pollutants can enter the wound and cause infection after the skin is damaged. As a result, the focus of early therapy for an open fracture is on avoiding infection at the site of the injury. The wound, tissues, and bone must be cleaned out as fast as feasible in surgical treatment. To allow the wound to heal, the shattered bone must also be stabilized. 
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Depending on the type and location of the fracture, the doctor may use the following treatments:

<ul>
	<li>Splint or Cast: Moving the broken bones can aggravate the pain and bleeding, as well as harm the tissues around the injury. This might eventually cause issues in the repair and healing of the damage. Therefore, it is crucial to provide proper fracture first-aid care. The goal of fracture first aid is to immobilize (restrict movement of) the wounded region while the bone heals. A splint or a cast is often used for immobilization. 
	&nbsp;</li>
	<li>Traction: Traction is the use of a consistent pulling motion to stretch certain sections of the body in one direction. Pulleys, strings, weights, and a metal frame mounted above or on the bed are commonly used. As the muscles and tendons stretch around the broken bones, the bone ends to align and heal. 
	&nbsp;</li>
	<li>Closed reduction: This is a non-surgical procedure and involves the doctor physically re-aligning the broken bones while pulling and pushing on the body on the outside. Sedatives or anesthesia may be administered during the procedure to prevent the individual from feeling pain. After the closed reduction, the doctor may place a cast or splint on the fractured area to help it heal. 
	&nbsp;</li>
	<li>Surgery: Certain forms of fractured bones may require surgery to be repaired. Internal fixation (metal rods or pins placed inside the bone) or external fixation devices (metal rods or pins placed outside the body) are occasionally used to keep bone fragments in place while they recover. 
	&nbsp;</li>
</ul>

<ol>
	<li>In&nbsp;Open Reduction and Internal Fixation, the doctor will first relocate or &quot;reduce&quot; the shattered bone parts into their natural alignment. The damaged bone will then be connected or &quot;fixed.&quot; This is accomplished by the use of screws, metal plates, rods, or intramedullary nails.</li>
	<li>External fixation:&nbsp;Involves inserting pins or screws into your bone above and below the fracture location. These pins or screws are attached to a metal stabilizing bar on the exterior of the skin. The metal bar keeps the bone in place as it heals.</li>
	<li>Arthroplasty:&nbsp;Also called joint replacement, it is performed when fractures cause extensive damage to the upper end of the humerus or femur.</li>
	<li>Bone grafting:&nbsp;In case of nonunion or delayed union, doctors may use bone grafts to rejoin the fractured bone 
	.</li>
</ol>

<ul>
	<li>Medication: The doctor may also prescribe medications to control pain (analgesics), fight infections, or manage other symptoms and complications. 
	&nbsp;</li>
</ul>

After the initial treatment, physical therapy or other strategies may be recommended to help the individual regain normal use. 
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NOTE: If you suspect a broken hip, back, or neck, or see an exposed bone, do not move the individual. Instead, immediately call for help. Moving the individual without immobilizing the fractured bone can result in nerve and vessel damage, leading to complications.
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Complications are more likely with open fractures (which are more prone to infection) and fractures that affect arteries, tissue perfusion, and/or nerves. Closed fractures that do not involve blood vessels or nerves, especially those that are rapidly reduced, are the least likely to cause major problems. 
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<ul>
	<li>Acute Compartment Syndrome (ACS) - This is a surgical emergency. It results from increased pressure within a closed fascial space, impairing circulation. If left untreated, it can result in ischemia and necrosis. Tibial shaft fractures are a common cause of acute compartment syndrome. &nbsp; &nbsp; 
	&nbsp;</li>
	<li>Bleeding: All fractures cause bleeding and soft-tissue injuries. Internal or external bleeding is only seldom severe enough to produce hemorrhagic shock, for example in pelvic, femoral, and some open fractures. 
	&nbsp;</li>
	<li>Vascular Injuries: Some open fractures cause blood vessels to rupture. Some closed fractures, especially posteriorly displaced supracondylar humeral fractures, disturb the vascular supply enough to produce distal limb ischemia. This vascular disruption may be clinically hidden for hours after the injury. 
	&nbsp;</li>
	<li>Nerve Injuries: These can occur when nerves are stretched by displaced broken bone fragments, bruised by a blunt impact, crushed in a severe crush injury, or ripped by sharp bone fragments. Nerve conduction is inhibited when nerves are bruised (neurapraxia), but the nerve is not severed. Neurapraxia results in transitory motor and/or sensory abnormalities. The neurologic function typically returns in 6 to 8 weeks. When nerves are crushed (axonotmesis), the axon is damaged but not the myelin sheath. This is more serious damage than neurapraxia. Depending on the severity of the injury, the nerve can heal in weeks to years. Nerves are commonly torn (called neurotmesis) in open fractures. 
	&nbsp;</li>
	<li>Pulmonary Embolism: The risk of pulmonary embolism is significant in individuals with a hip or pelvic fracture. The most common fatal consequence of major hip or pelvic fractures is pulmonary embolism. 
	&nbsp;</li>
	<li>Fat Embolism: Long bone fractures (most typically, femoral fractures) can cause fat (and other marrow contents) to embolize to the lungs, resulting in pulmonary embolism and associated respiratory problems. 
	&nbsp;</li>
	<li>Infection: Any fracture has the potential to get infected, but those that require open surgery or medical intervention have the highest risk. Acute infection can cause osteomyelitis, which is difficult to treat. 
	&nbsp;</li>
	<li>Osteonecrosis: When the vascular supply to a fracture fragment is compromised, a portion of the fracture fragment can become necrotic. Scaphoid fractures, displaced femoral neck fractures, and displaced neck fractures are examples of closed fractures that are prone to osteonecrosis. 
	&nbsp;</li>
	<li>Instability: A variety of fractures can result in joint instability. Instability can be debilitating and raises the risk of osteoarthritis.&nbsp; &nbsp; &nbsp; Fractures that extend into joints frequently disturb articular cartilage; misplaced articular cartilage tends to scar, producing osteoarthritis and restricting joint mobility. Stiffness is more prevalent when a joint is immobilized for an extended period of time. Post-traumatic stiffness is most common in the knee, elbow, and shoulder, especially in the elderly. 
	&nbsp;</li>
	<li>Malunion: This happens when your broken bones don&rsquo;t line up correctly while they heal. 
	&nbsp;</li>
	<li>Nonunion: Your bones may not grow back together fully or at all. 
	&nbsp;</li>
	<li>Other Internal Damage: Fractures can harm the muscles, nerves, blood vessels, tendons, and ligaments in the area around the injury. 
	&nbsp;</li>
</ul>
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Weakening of the bone is the most crucial risk factor which can occur due to following: 
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Modifiable Risk Factors:

<ul>
	<li>Low vitamin-D</li>
	<li>Smoking</li>
	<li>Alcohol consumption</li>
	<li>&nbsp;Glucocorticoid use 
	&nbsp;</li>
</ul>

Non-Modifiable Risk Factors:

<ul>
	<li>Increasing age</li>
	<li>Congenital disorders, such as osteogenesis imperfecta</li>
	<li>Malabsorption problems that may impair the ability to absorb important nutrient including calcium and vitamin D</li>
</ul>
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To minimize the risk factors, follow these general safety guidelines:

<ul>
	<li>Always wear a seatbelt.</li>
	<li>Wear the appropriate safety equipment for all sports activities.</li>
	<li>Maintain a clutter-free home and workstation to avoid tripping yourself or others.</li>
	<li>To access items at home, always use the right tools or equipment. Never stand on chairs, tables, or counters, as it may increase the risk of a fall.</li>
	<li>Maintain optimal bone health by following a diet and activity regimen.</li>
	<li>Quit smoking as tobacco and nicotine can increase the risk of fractures and slow down healing.</li>
	<li>If you&#39;re over 50 or have a family history of osteoporosis, talk to your doctor about getting a bone density test.</li>
	<li>If you have trouble walking or are in danger of falling, use a cane or walker. 
	&nbsp;</li>
</ul>
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Key Points

<ul>
	<li>A fracture is defined as a complete or partial break in a bone that occurs when the physical force applied to the bone is stronger than the bone itself.</li>
	<li>Fractures can occur due to trauma associated with a fall, sports injury, or motor vehicle crash. This disrupts the bone&#39;s structure and strength, resulting in discomfort, loss of function, and, in certain cases, bleeding and damage surrounding the location.</li>
	<li>Fractures are categorized based on their direction, mechanism, whether or not the skin is fractured, and location. </li>
	<li>When the first damage occurs, most fractures are followed by excruciating agony. When you move or touch the damaged region, it may worsen. In certain situations, the discomfort may cause you to faint. You may also feel dizzy or chilly as a result of the shock.</li>
	<li>If you suspect a fracture, get medical assistance right away. Your doctor will take a comprehensive medical history (including asking how the injury happened). You will also be subjected to a physical examination. They may instruct you to move the affected part in certain ways to check the pain or other indicators of damage.</li>
	<li>An X-ray is often the preferred diagnostic method for fractures. However, if an X-ray is inconclusive in identifying a fracture, doctors may perform MRI and CT scans. </li>
	<li>The aim of treatment is to re-align the broken bone fragments and prevent any disability. This can be achieved by splints or casts and surgical procedures, such as internal or external fixation.</li>
	<li>Complications are more likely with open fractures (which are more prone to infection) and fractures that affect blood arteries, tissue perfusion, and/or nerves. Closed fractures that do not involve blood vessels or nerves, especially those that are rapidly reduced, are the least likely to cause major problems.</li>
</ul>
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[2] Bone fractures: Types, symptoms & treatment. Cleveland Clinic.

[3] Fracture. MedlinePlus. Accessed December 12, 2022.

[4] Fractures: Types, causes, symptoms, and treatment. Medical News Today.  Accessed December 12, 2022.

[5] Fractures. Fractures | Johns Hopkins Medicine. Published February 28, 2020. Accessed December 12, 2022.

[6] Types of bone fractures: Buckle fracture, stress fracture, comminuted fracture, and more. WebMD. Accessed December 12, 2022.

[7] Giorgi A. Fracture | definition and patient education. Published July 9, 2017. Accessed December 12, 2022.

[8] Fractures (broken bones) - orthoinfo - aaos. OrthoInfo. Accessed December 12, 2022.

[9] 9.	Fractures. Fractures - Health Encyclopedia - University of Rochester Medical Center. Accessed December 12, 2022.

[10] Campagne D. Overview of fractures - injuries; poisoning. Merck Manuals Professional Edition Published November 18, 2022. Accessed December 12, 2022.

[11] Wu A-M, Bisignano C, James SL, et al. Global, regional, and national burden of bone fractures in 204 countries and territories, 1990–2019: A systematic analysis from the global burden of disease study 2019. The Lancet Healthy Longevity. 2021;2(9). doi:10.1016/s2666-7568(21)00172-0

[12] Khan AH, Jafri L, Ahmed S, Noordin S. Osteoporosis and its perspective in Pakistan: A review of evidence and issues for addressing fragility fractures. Annals of Medicine and Surgery. 2018;29:19-25.