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Bone fracture

1. A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in


which there is a break in the continuity of the bone.
2. When a fracture occurs, it is classified as either open or closed:

• Closed fracture (Also called simple fracture.) - The bone is broken, but the skin is
intact.
• Open fracture (Also called compound fracture.) - The bone exits and is visible
through the skin. It has different classification:

a. Type I
➢ Wound less than 1 cm with minimal soft tissue injury
➢ Wound bed is clean
➢ Fracture is usually a simple transverse, short oblique fracture, with minimal
comminution
b. Type II
➢ Wound is greater than 1 cm with moderate soft tissue injury
➢ Fracture is usually a simple transverse, short oblique fracture, with minimal
comminution
c. Type III
➢ Fractures that involve extensive damage to the soft tissues, including muscle,
skin and neurovascular structures.
➢ Special patterns classified as Type III:
▪ Farm injuries, with soil contamination, irrespective of the size of the
wound.
▪ Open segmental fracture, irrespective of the size of the wound
▪ Gunshot wounds
▪ Open fractures over 8 hours old
▪ Traumatic amputations
Mechanisms of fracture:
Classical signs of fracture
1. Pain and tenderness
a. Although bone tissue itself contains no nociceptors, bone fracture is painful for
several reasons:
• Breaking in the continuity of the periosteum, with or without similar
discontinuity in endosteum, as both contain multiple nociceptors.
• Edema of nearby soft tissues caused by bleeding of torn periosteal blood
vessels evokes pressure pain.
• Muscle spasms trying to hold bone fragments in place
2. Deformity
3. Swelling
4. Haematoma, haemarthrosis
5. Abnormal mobility, occasionally crepitus
6. Loss of function
7. Local temperature increase

Diagnosis
1. Clinical assessment for complicating injuries
2. Plain x-rays
a. A fracture's appearance on x-rays can be described in terms:

Common types of fracture:


Fig. 1

Greenstick - incomplete fracture. The


broken bone is not completely separated.

Transverse - the break is in a straight line


across the bone.
Spiral - the break spirals around the
bone; common in a twisting injury.

Oblique - diagonal break across the bone.

Compression - the bone is crushed,


causing the broken bone to be wider or
flatter in appearance.

Segmental fractures- 2 separate breaks


in a bone.

Comminuted Fracture- the injury results


in multiple breaks in the bone, they are
visible as different fragments.
Avulsion fractures are caused by a
tendon dislodging a bone fragment.

Impacted fractures- bone fragments are


driven into each other, results to
shortening of the bone;

Torus fractures- buckling of the bone


cortex.

b. Spatial relationship between fracture fragments can be classified into:


Fig. 2

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.

Shortening- is proximal migration of the


distal fracture component results in
shortening of the overall bone length.

Fig. 3
3. Sometimes CT or MRI

Causes:

1. Traumatic- This is due to sustained trauma brought about by impact or stress. e.g.
- Fractures caused by a fall, road traffic accident, fight etc.
2. Pathological- A fracture through a bone which has been made weak by some
underlying disease. e.g. - Osteoporosis, bone cancer.

Anatomical location of fracture

1) A skull fracture is a break in one or more of the eight bones that form the cranial
portion of the skull, usually occurring as a result of blunt force trauma.

Four common types of skull fractures:


Linear fractures- breaks in the bone that
transverse the full thickness of the skull
from the outer to inner table, are usually
fairly straight and involve no
displacement of the bone.

Depressed fractures- which are


usually comminuted with broken
portions of bone displaced inward may
require surgical intervention if there is
underlying tissue damage

Diastatic fractures- the sutures of the


skull widen usually affects children
under three.

Basilar fractures which occur in the


bones at the base of the skull.
The temporal bone fracture is
encountered in 75% of all basilar skull
fractures. And it also includes breaks in
the posterior skull base or anterior skull
base.
Signs and symptoms of skull fracture

Battle's sign - is ecchymosis of the mastoid


process of the temporal bone.

Raccoon eyes - is periorbital ecchymosis.

Hemotympanum- refers to the presence of


blood in the tympanic cavity of the middle
ear.

CSF rhinorrhoea- refers to the drainage


of cerebrospinal fluid through the nose. It
has also been noted to be characterized by
unilateral discharge.

CSF Otorrhea- refers to the drainage


of cerebrospinal fluid through the ear. It has
also been noted to be characterized by
unilateral discharge.

Measures of CSF components:

Beta-2 transferrin is a carbohydrate-free


(desialated) isoform of transferrin, which is
almost exclusively found in the cerebrospinal
fluid. It is not found in blood, mucus or tears,
thus making it a specific marker of
cerebrospinal fluid, applied as an assay in
cases where cerebrospinal fluid leakage is
suspected.

Nose and Ear bleeding

2) Facial fractures
a) Nasal fracture, commonly referred to as a broken nose, is a fracture of one of
the bones of the nose.
b) Le Fort fractures of skull- are types of facial fractures involving the maxillary
bone and surrounding structures in a usually bilateral and horizontal, pyramidal or
transverse way.
Classifications

Le Fort I fractures (horizontal) may result


from a force of injury directed low on the
maxillary alveolar rim in a downward
direction. It is also known as a Guerin
fracture or 'floating palate', and usually
involves the inferior nasal aperture. The
fracture extends from the nasal septum to
the lateral pyriform rims, travels
horizontally above the teeth apices, crosses
below the zygomaticomaxillary junction,
and traverses the pterygomaxillary junction
to interrupt the pterygoid plates.

Le Fort II fractures (pyramidal) may


result from a blow to the lower or mid
maxilla and usually involve the inferior
orbital rim. Such a fracture has a pyramidal
shape and extends from the nasal bridge at
or below the nasofrontal suture through the
frontal processes of the maxilla,
inferolaterally through the lacrimal bones
and inferior orbital floor and rim through or
near the inferior orbital foramen, and
inferiorly through the anterior wall of the
maxillary sinus; it then travels under the
zygoma, across the pterygomaxillary
fissure, and through the pterygoid plates.
Le Fort III fractures (transverse) are
otherwise known as craniofacial
dissociation and involve the zygomatic
arch. These may follow impact to the nasal
bridge or upper maxilla. These fractures
start at the nasofrontal and frontomaxillary
sutures and extend posteriorly along the
medial wall of the orbit through the
nasolacrimal groove and ethmoid bones.
The thicker sphenoid bone posteriorly
usually prevents continuation of the
fracture into the optic canal. Instead, the
fracture continues along the floor of the
orbit along the inferior orbital fissure and
continues superolaterally through the
lateral orbital wall, through the
zygomaticofrontal junction and the
zygomatic arch. Intranasally, a branch of the
fracture extends through the base of the
perpendicular plate of the ethmoid, through
the vomer, and through the interface of the
pterygoid plates to the base of the sphenoid.
This type of fracture predisposes the
patient to CSF rhinorrhea more commonly
than the other types.

c) Mandibular fracture- also known as fractures of the jaw, are breaks through the
mandibular bone. The types of mandibular fractures include fractures at the
symphyseal area, horizontal ramus, mandibular angle and condylar neck.

3) Spinal fracture (or vertebral fracture) is a fracture affecting the bones of the spinal
column.
a) Cervical fracture commonly called a broken neck is a catastrophic fracture of any of
the seven cervical vertebrae in the neck. Abnormal movement of neck bones or pieces
of bone can cause a spinal cord injury resulting in loss of sensation, paralysis, or
death.
Common types:

Jefferson fracture is a bone


fracture of the anterior
and posterior arches of the C1
vertebra. It is often caused by an
impact or load on the back of the
head, and are frequently associated
with diving into shallow water.

A hangman's fracture- a fracture of


both pedicles or pars
interarticularis of the axis
vertebra (C2).
The mechanism of the injury is
forcible hyperextension of the head,
usually with distraction of the neck.

A flexion teardrop fracture is


a fracture of the anteroinferior
aspect of a cervical vertebral body
due to flexion of the spine along with
vertical axial compression.[1] A
teardrop fracture is usually
associated with a spinal cord injury,
often a result of displacement of the
posterior portion of the vertebral
body into the central spinal canal.

Clay-shoveler's fracture is a
stable fracture through the spinous
process of a vertebra occurring at
any of the lower cervical or upper
thoracic vertebrae, classically at
C6 or C7.
A burst fracture is a type of
traumatic spinal injury in which
a vertebra breaks from a high-
energy axial load (e.g., car accidents
or falls from a great height or high
velocity), with all or pieces of the
vertebra shattering into
surrounding tissues and sometimes
the spinal canal.

A compression fracture is a
collapse of a vertebra. It may be due
to trauma or due to a weakening of
the vertebra (compare with burst
fracture).

Chance fracture is a flexion injury


of the spine. It consists of a
compression injury to the anterior
portion of the vertebral body and a
transverse fracture through the
posterior elements of the vertebra
and the posterior portion of the
vertebral body. It is caused by
violent forward flexion, causing
distraction injury to the posterior
elements.

4) Clavicle fracture- is a bone fracture in the clavicle, or collarbone. It is often caused by a


fall onto an outstretched upper extremity, a fall onto a shoulder, or a direct blow to the
clavicle.
5) Scapular fracture- is a fracture of the scapula, the shoulder blade.

6) Humerus fracture can be classified by the location of the humerus involved: the upper
end, the shaft, or the lower end.

Fracture of the greater tuberosity of the humerus Supracondylar fracture is a fracture, usually of
the distal humerus just above the epicondyles,
although it may occur elsewhere.

Proximal humerus fracture Medial humerus fracture

7) Ulnar fracture

a) Monteggia fracture- is a fracture of the proximal third of the ulna with


dislocation of the head of the radius.
b) Hume fracture- is a fracture of the olecranon with an
associated anterior dislocation of the radial head.

8) Radial fracture

a) Distal radius fracture- is a common bone fracture of the radius in the forearm.
Because of its proximity to the wrist joint, this injury is often called a wrist
fracture.
o Galeazzi fracture - a fracture of the radius with dislocation of the distal
radioulnar joint
o Colles' fracture - a distal fracture of the radius with dorsal (posterior)
displacement of the wrist and hand
o Smith's fracture - a distal fracture of the radius with volar (ventral)
displacement of the wrist and hand
o Barton's fracture - an intra-articular fracture of the distal radius with
dislocation of the radiocarpal joint.
9) Scaphoid fracture- also known as the carpal navicular, is the most common type of
carpal bone fracture.
a. Rolando fracture- is a comminuted intra-articular fracture through the base of
the first metacarpal bone (the bone located just proximal to the thumb). This is a
fracture consisting of 3 distinct fragments; it is typically T- or Y-shaped.

b. Bennett's fracture- is a fracture of the base of the first metacarpal bone which
extends into the carpometacarpal (CMC) joint. This intra-articular fracture is the
most common type of fracture of the thumb, and is nearly always accompanied by
some degree of subluxation or frank dislocation of the carpometacarpal joint.
c. Boxer's fracture- occurs as a result of axial loading of the 4th and/or 5th
transverse neck of the metacarpal bone secondary to an indirect force such as
striking an object with a closed fist.

10)Pelvic fracture- is a disruption of the bony structure of the pelvis, including the hip,
bone, sacrum and coccyx.
a) Duverney fractures are isolated pelvic fractures involving only the iliac wing.
They are caused by direct trauma to the iliac wing, and are generally stable
fractures as they do not disrupt the weight bearing pelvic ring.

b) Malgaine’s Fracture- Double fracture of the pelvic ring causing instability of the
pelvis.

11) Femoral fracture is a bone fracture that involves the femur. It includes hip fractures.
Femoral head fracture denotes
____________________________. This is usually
the result of high energy trauma and a
dislocation of the hip joint often
accompanies this fracture.

Femoral neck fracture can be of 2 types:

Intracapsular Fracture/Subcapital
Neck Fracture) - This fracture occurs at
the level of the _________________ and may
have loss of blood supply to the bone.

Transcervical neck fracture- Occurs at


the mid-part of the femoral neck.

Intertrochanteric Fracture- occur


between the_______________________

Subtrochanteric Fracture- actually


involves the shaft of
the femur immediately below the lesser
trochanter and may extend down the shaft
of the femur.
Greater trochanteric fracture

Lesser trochanteric fracture

a) Hip fracture is a femoral fracture that occurs in the proximal end of


the femur (the long bone running through the thigh), near the hip.

b) Femoral head fracture denotes a fracture involving the femoral head. This is
usually the result of high energy trauma and a dislocation of the hip joint often
accompanies this fracture.

c) Femoral neck fracture can be of 2 types:


Subcapital, or intracapsular fracture- This fracture occurs at the level of the
femoral neck and may have loss of blood supply to the bone.

Transcervical neck fracture- Occurs at the mid-part of the femoral neck.

d) Subtrochanteric fracture actually involves the shaft of the femur immediately


below the lesser trochanter and may extend down the shaft of the femur.
e) Intertrochanteric fractures- occur between the greater and lesser trochanters.
They are usually fixed with a sliding hip screw and plate. Healing is usually good
when the patient is healthy.

12) Patella fracture is a fracture of the kneecap, which is one of the most common knee
injuries. It is usually the result of a hard blow to the front of the knee.

13)Crus fracture- is a fracture of either or both of the tibia and fibula.


Fractures of only the tibia include:

➢ Bumper fracture - a fracture of the lateral tibial plateau caused by a


forced valgus applied to the knee.

➢ Segond fracture - an avulsion fracture of the lateral tibial condyle


➢ Toddler's fracture - an undisplaced and spiral fracture of the distal third to distal half
of the tibia.

Fractures of only the fibula include:

➢ Le Fort fracture of ankle - a vertical fracture of the antero-medial part of


the distal fibula with avulsion of the anterior tibiofibular ligament.

Combined tibia and fibula fractures include:

➢ Trimalleolar fracture - involving the lateral malleolus, medial malleolus and the
distal posterior aspect of the tibia.
➢ Bimalleolar fracture - involving the lateral malleolus and the medial malleolus.

➢ Pott's fracture- a fracture of the lower end of the fibula, usually involving a
dislocation of the ankle.
14) Lisfranc injury (also known as the Lisfranc fracture, Lisfranc dislocation, Lisfranc
fracture dislocation, tarsometatarsal injury, or simply midfoot injury) is an injury of
the foot in which one or all of the metatarsal bones are displaced from the tarsus.
Three classifications:

1. Homolateral: All five metatarsals are displaced in the same direction.


2. Isolated: one or two metatarsals are displaced from the others
3. Divergent: metatarsals are displaced in a sagittal or coronal plane.
a) Jones fracture- is a fracture of the diaphysis of the fifth metatarsal of the foot. The
fifth metatarsal is at the base of the small toe. The proximal end, where the Jones
fracture occurs, is in the midportion of the foot.

b) March fracture, also known as fatigue fracture or stress fracture of metatarsal


bone, is the fracture of the distal third of one of the metatarsals occurring because
of recurrent stress. It is more common in soldiers, but also occurs in hikers,
organists, and even those, like hospital doctors, whose duties entail much standing

c) Calcaneal fracture, also known as Lover's fracture and Don Juan fracture, is
a fracture of the calcaneus.
o Why is it called a “Lover’s fracture?”
▪ Because it is the type of fracture that could presumably be caused

by a lover jumping out of the bedroom window to escape from a

surprised and enraged spouse