This is the most comprehensive guide to bone fractures.
What are their symptoms?
What are their complications?
How long does it take for a bone to heal?
In this guide you will learn everything about bone fractures.
Bone fracture is a break in the surface of a bone, either across its cortex or through its articular surface.
The mechanism of injury is defined by:
Clinical picture and symptoms:
The classic symptoms of a fracture are:
Swelling: pathologic-type swelling, and increased volume of the structure, caused by the presence of lymphatic fluid in the tissues (edema).
Pain: which is always present and increases with movement and with the palpation of the affected segment. It may be mild, moderate and severe and may be due to tearing of the periosteum (the external layer), soft tissue injury, vascular injury, nerve injury, etc.
Deformity: caused by the displacement of the bones, as often happens in displaced fractures, and by the increase of the tissue volume, caused by edema.
Abnormal mobility: Sometimes the limitation of movement is so relevant that the subject is unable to move the affected segment.
Loss of stability and natural movement of the compromised anatomical area.
The classification of the bone fracture can be defined by many factors.
Depending on the area of the bone involved, fractures may be:
Direct impact trauma: when the bone fractures at the point of application of the injury force:
Indirect trauma: when the damaging force acts at a distance from the fracture site, spreading along the entire limb or along the spine until it reaches the fracture site:
a) Internally open (from within): The sharp fracture end pierces the skin from within, resulting in an open fracture.
b) Externally open (open from outside): The object causing the fracture lacerates the skin and soft tissues over the bone, as it breaks the bone, resulting in an open fracture.
Exposure of an open fracture to the external environment makes it at high risk to infection.
a) Incomplete fracture: it involves only one surface or the cortex of the bone.
For example, greenstick fractures are seen exclusively in children.
Here the bone is elastic and usually bends due to buckling or breaking one cortex when a force is applied.
b) Complete fracture: the bone is completely broken.
Pathological fractures: when a bone has been weakened by a pathological condition, even minor stresses can cause a break in the structure.
They occur as a spontaneous failure of the diseased bone or from the application of a light or moderate force.
For example, as occurs in the case of some neoplastic diseases (benign or malignant), or also in other diseases that can cause skeletal fragility, such as osteoporosis, bone tumors, etc.
Stress fractures: when a low intensity force is continuously repeated over time, on a specific point of a structure, can cause a stress fracture.
They occur mostly in the lower limbs and in bones subjected to prolonged workload.
The functional overload that derives from the continuous stresses on the bone is typical of sportsmen.
For example, as occurs in some sports such as dance, running, etc.
Normally, the bone damaged by these small micro traumas tends to self-repair during periods of rest.
If an athletic gesture applies a continuous force in the same area that has previously suffered a light damage, it causes a further weakening of the structure, and, over time, the creation of a stress fracture.
The complications of fractures are rare but can threaten the vitality of the structure affected or cause a permanent alteration of the functional movement, up to involve the whole organism.
In case of open fractures, the risk of further complications is high (which usually brings an infection), due to the involvement of other structures surrounding the fractured bone, such as blood vessels, tissues, and nerves.
Closed fractures that do not involve other structures, especially those that are rapidly reduced, are less likely to cause serious complications.
Acute complications include all the problems that occur at the time of the trauma, or during the following days:
Hemorrhage: A common feature of all fractures and soft tissue injuries.
Rarely, internal or external bleeding is severe enough to cause an hemorrhagic shock (for example, as occurs in hip fractures and some open fractures).
Skin lesions: generally occur in displaced open fractures, in which the exposure must be immediately identified, to avoid a becoming infection.
Vascular injuries: some displaced and open fractures tear blood vessels.
Some closed fractures, particularly supra-condylar humeral fractures located both anteriorly and posteriorly, interrupt the vascular supply sufficiently to cause an ischemia (Volkmann syndrome).
The vascular lesion may not be clinically visible, even for a few hours after the injury.
Nerve Injury: bone fragments can damage nerves, if they apply a pression that compresses them, or if sharp bone fragments cut them.
If the nerve injury is caused by a prolonged compression or by a compromised nerve sheath that lines the nerve (myelin sheath), or by a temporary block of the nerve conduction (which can last from a few days to a few months), with the gradual resumption of motor and sensory activity (if the nervous structure is intact, the nerve tends to heal spontaneously).
When the lesion is total, then the nerve has been torn or cut completely, and the sensitivity and the ability to move the structure are compromised.
In this case the only plausible solution is through an immediate surgery.
Pulmonary embolism or thrombosis (DVT): in patients with hip and pelvic fractures, the risk of pulmonary embolism is high.
Pulmonary embolism is the most common fatal complication of hip and pelvic fractures.
It is mostly detected when the patient has an “air hunger syndrome”, with breathing difficulty, cough, tachycardia, etc.
That’s why after a surgery treatment, a drug therapy based on heparin is generally prescribed.
It allows to make the blood more fluid and to prevent obstructions in the blood vessels.
Fat embolism syndrome: this is one of the most serious complications, the essential feature being occlusion of small vessels by fat globules.
The fat globules may originate from bone marrow or adipose tissue.
Fat embolism is more common following severe injuries with multiple fractures and fractures of major bones.
Compartment syndrome (Volkmann): it is a syndrome characterized by an increase in pressure within a circumscribed anatomical area (as occurs mostly in fractures of the radius and ulna, in humeral fractures near the elbow, in tibial plateau fractures, and with open fractures of the tibia).
The increase in pressure interrupts the blood circulation and the tissues of that anatomical district (tendons, ligaments, muscles, nerves) no longer receive (or partially) supplements and oxygen.
The consequence of this syndrome, if not picked up on time, brings to a tissue necrosis or death of the affected structure.
The result of the muscles affected by necrosis is a deformity and a nervous deficit, up to the total lack of sensibility.
Compartment syndrome threatens the vitality and survival of the limb, even to the point of requiring an amputation.
The therapy consists in a decompression through fasciotomy surgery.
The anterior lodge of the forearm is incised, from the elbow to the carpal tunnel.
The incision should be left open until the edema resolves; after that the anatomical compartment is closed with a suture or skin graft.
Infection: contamination of the wound with bacteria from the outside environment may lead to infection of the bone(osteomyelitis).
This is when these microorganisms invade the membrane, unleashing an inflammatory reaction, which can lead to the formation of pus.
It occurs more commonly in open fractures, particularly in those where compounding occurs from outside (external compounding).
The increasing use of operative methods in the treatment of fractures is responsible for the rise in the incidence of infection of the bone, often years later. Infection may be superficial, moderate (osteomyelitis), or severe (gas gangrene).
A normal consolidation of a fracture should be the result of the formation of the callus, sufficient to withstand the strain.
Once the bone consolidation and healing time has expired, the absence of evidence that the lesion has been repaired can lead to:
Instability: some fractures can lead to joint instability.
Instability can bring disabilities and increases the risk of osteoarthrosis.
Stiffness and movement reduced: fractures that extend to the surface of the joint often damage the joint cartilage.
An alteration of the cartilage surface leads to a scar, which causes osteoarthrosis and compromises the movement of the joint.
Stiffness is more likely after a prolonged immobilization.
Knees, elbows and shoulders are particularly incline to post-traumatic stiffness, especially in old age.
The main factors are given by:
Pseudarthrosis: complete and irreversible compromisation of bone healing, in which little or no callus forms and bone resorption occurs at the fracture site.
It is a pathological situation because a particular tissue called fibrous and fibrous-cartilaginous (the one that can be found in scars and vertebral discs) is formed between the fracture fragments.
The body perceives the bone fragments as if they were separate bones, therefore it tries to join them together.
Bad Consolidation: Occurs when fracture fragments heal in an incorrect position, causing clinical and aesthetic deformity.
It can occur when a fracture has not been adequately reduced and stabilized.
Through corrective osteotomies (surgical operations in which the bone is cut with the intent to correct its shape), the lesion is restored to its normal skeletal morphology and the fragments are stabilized in the desired position, through different osteosynthesis devices.
Wedge osteotomies of equal size are then performed in opposite directions, which can be used to correct a translational deformity and restore mechanical axis alignment of the lower extremity.
Osteonecrosis: Part of a fracture fragment can become necrotic, especially when the vascular supply is damaged.
Closed fractures at risk of osteonecrosis are carpal scaphoid fractures, displaced femoral neck fractures, and displaced talar neck fractures.
Arthrosis: fractures that interrupt the continuity of a joint can cause joint misalignment, resulting in instability and future degeneration of the joint cartilage.
Limb-length discrepancy: when a fracture in children involves a growth epiphyseal plate, growth itself can be affected, resulting in a shorter than the other one.
In adults, surgical repairs of a fracture, particularly hip fractures, can cause a leg length discrepancy, which can lead to a difficult deambulation and the necessity of a footbed for the shorter leg.
Algodystrophy (Sudek’s disease or CRPS): it is defined as a complex regional pain syndrome.
The causes are currently unknown; it can be imputed to a presence of an initiating noxious event, or a cause of immobilization.
It affects the arms, hands, legs and feet.
CRPS describes an array of painful conditions that are characterized by a continuing (spontaneous and/or evoked) regional pain that is seemingly disproportionate to the usual course of any known trauma or other lesion.
The pain is regional and the person has a sensation of burning, stiffness, sweaty and shiny skin, edema, muscle contraction disorders, color change of the anatomical structure concerned, pain that remains present even when the painful stimulus is no longer present.
There are two types:
Type 1 CRPS (as previously mentioned) occurs following a trauma such as fractures, sprains, surgery, and repeated microtrauma.
Type 2 CRPS occurs following an injury to a nerve branch.
Osteomyelitis: it is an inflammatory process that affects both the external and the internal component of the bone, including the bone marrow.
The most common cause is bacterial or fungal.
The infection causes the formation of abscesses.
The pus thus formed finds its way out through the area of least resistance.
The developed abscess spreads through the soft tissues and outwards, forming a breast that breaks the skin, or slips down, towards the shaft, between the cortex and the periosteum.
Post-traumatic aseptic avascular necrosis: due to an insufficiency or lack of blood supply, all the cells of a portion of the bone tissue die, not for causes associated with infections or the introduction of bacteria that damage the structure.
In severe cases it leads to bone collapse.
The clavicle is the most commonly injured bone during birth (accounts for 40 to 50% of all birth injuries), followed by brachial plexus injury (usually during instrumental rotation of the vertex), the humerus (injured during breech delivery) and the femur in that order.
This kind of bone has a tendency to spontaneous healing faster than others.
The mechanism of injury is purely indirect, although in some cases it occurs directly.
The mechanism of injury is purely indirect, although in some cases it occurs directly.
It is caused by a road traffic accident and due to a fall on the point of the shoulder.
The first thing you may feel is:
Rarely, you may present a pseudo-paralysis of the affected arm.
In this case the closest fracture fragment by the neck is displaced superiorly, as well as it becomes visible and palpable.
The lateral fragment, on the other hand, tends to fall down due to the weight of the arm and the traction of the pectoralis major.
You should find yourself assuming a kind of defensive position, in which the opposite arm supports your affected elbow, with the hand and your head that tends to tilt towards the fractured area, in order to relax the muscular structures that intervene on the clavicle.
It is necessary to be careful in children, because the fracture fragment is not always visible.
They are rare, but they can also be very serious, such as lesions of the lungs and the pleura (the layer that lines the lungs).
In children (and infants) bone healing is spontaneous.
The treatment of choice in fracture clavicle consists of the following methods:
Surgical treatment: is indicated in case of fracture displacements and exposures and consists of open reduction and rigid internal fixation.
The common internal fixation methods are:
Fractures of the scapula are among the least frequent, as it is a bone covered by muscle masses that completely surround it and in most cases they are not important, because patients recover well even without many treatments.
The exception is given by the glenoid margin, which suffers damage mainly related to the dislocations of the arm bone, the humerus.
An high-intensity trauma is the main cause of scapular fractures, and also of other collateral damages, such as rib fractures, vertebral fractures, bruises, etc.
The mechanism of injury is given by a direct blow (fall of a heavy object on the shoulder blade) or axial loading on the outstretched hands.
Fractures of the scapula are classified according to the anatomical location:
Similarly to the fractures of the clavicle, you may experience:
The most relevant complication during scapular joint fractures is post-traumatic shoulder osteoarthritis.
This pathology does not occur immediately after the trauma, but tends to manifest itself over a longer period of time.
Undisplaced scapular fractures may be treated conservatively with rest, sling, strap, etc.
Displaced fractures need open reduction and internal fixation with K-wires, screws, etc.
Arm fractures are characterized by all those skeletal injuries affecting the humerus, the arm bone.
They are classified according to the area of injury:
They are found more in elderly patients, in whom some pathologies such as osteoporosis, can cause an injury, also due to a low intensity force on the limb.
The traumatic mechanism is generally indirect, so the impact from a fall does not occur directly on the fracture area, as much as from falls on the shoulder, elbow and hand, in a defensive attitude.
Fractures of the proximal humerus are classified into:
Surgical neck fractures:
These type of fractures are defined by an absence of displacement of the fragments, or by their decomposition, or by impacted fragments – here the fracture fragments are impacted into each other and are not separated and displaced – or from the dislocation of the body of the bone towards the armpit.
The first thing you may feel is:
The main feature in this type of fracture is the blood extravasation in the arm, chest and armpit, caused by the trauma (Hennequin sign):
Undisplaced and impacted fractures the limb are immobilized with a brace (Desault) for approximately 30 days, followed by an early rehabilitation program for the recovery of the shoulder joint and to avoid joint stiffness.
It is performed in displaced fractures and fracture with dislocations, respectively through Kirschner wires and screws and osteosynthesis with plate and screws.
Humerus greater tuberosity fracture:
Humerus greater tuberosity fractures are more common than previous types and are also often associated with humeral head luxation.
The mechanism of injury is caused by the direct type or by avulsion/tearing.
As with surgical humerus neck fractures, if the fracture is compounded, then therapy will focus on maintaining a Desault brace for 20-30 days.
If the fracture is displaced, with the ascent of the fragment upwards (which could create an attraction and a block of the shoulder joint), we proceed with the osteosynthesis of the fragment.
Fractures of the humeral anatomic neck:
Fractures of the humeral anatomic neck are very rare and are characterized by a real decapitation of its head.
The possible complication of this type of injury is the humerus head necrosis (neither caused by battery infection, nor by blockage of a blood vessel).
As well as surgical neck and greater tuberosity fractures, conservative therapy consists of a Desault brace for 20-30 days when the fracture is not displaced.
If the fracture is displaced, they might proceed with an osteosynthesis of the fragment.
Humerus head fractures:
Conservative treatment: When the fracture is non-displaced, conservative therapy consists of a Desault brace for 20-30 days.
Surgical treatment: in some cases where a burst fracture is present, the remaining fragments are surgically removed and the humeral head is replaced by implanting a partial shoulder prosthesis.
Fracture shaft humerus is more common in adults than in children.
Next to clavicle, this is the second most common birth fractures.
In elderly patients, some pathologies like osteoporosis, can cause injuries, also due to a low intensity force on the limb.
The mechanism of injury may be caused by:
Direct force: This may produce a transverse or comminuted fracture.
Indirect force: It is due to fall on an outstretched hand
and this will produce an oblique or spiral fracture.
Birth injuries: This is the second most common birth
fracture after clavicle.
Fractures of the humeral shaft occur due to direct high intensity and energy trauma, as occurs for example in road accidents.
Depending on the fracture site, the proximal segment (closest to the shoulder) can move anteriorly or posteriorly.
This consists of immobilization of the limb with a thoraco-brachial brace for up to 3 months.
Elbow joint is the most notorious joint in the body for it is associated with many complications following injury or trauma to the elbow.
Fall on the outstretched hands is more common in children because they are more playful and hence more prone to fall.
It easily becomes stiff and offers stiff resistance to the efforts of treating doctors to make it mobile again.
A timely rehabilitation is therefore necessary to avoid future joint stiffness.
Elbow fractures include distal humerus fracture and those of the closest extremities of the ulna and radius.
They are classified into:
They are more common in children between 5 and 10 years.
Figure A: flexion type:
The mechanism of injury is indirect, by fall on an outstretched hand, while the elbow is kept taut.
In the flexion type, it runs downwards and forwards.
Figure B: extension type:
The mechanism of injury is direct, due to a violent impact from behind, with the elbow flexed.
In extension type, the fracture line runs upwards and backwards.
The feeling that you can experience may be:
Initially in case of a compound fracture, closed reduction is tried under general anesthesia by traction and counter traction methods.
The medial and lateral tilt is corrected first and posterior displacement next and an arm cast with the elbow flexed is applied (the left image below).
Check radiograph is taken and all the angles so far discussed should be restored to normality, failure of which requires considering alternative methods of treatment like skeletal traction or open reduction and internal fixation.
Traction methods are indicated if conservative methods fail and in displaced fractures too (the right image below).
They consist of skin or skeletal traction and are of historical importance of late due to the availability of better and effective treatment methods.
The patient is placed on the bed, in supine decubitus (lying on the back), with the elbow bent at 90 °.
A transolecranon traction is applied, which supports the arm upwards (this method of surgical treatment allows to reduce the bone fragments displacement, compressions on the vascular and nerve structures and edema reduction, which by force of gravity, flows up to the axillary lymph nodes, where are definitively disposed).
What to do in case of further complications in supracondylar fractures:
Fracture olecranon is uncommon in children.
In adults it is comparable to fracture patella.
Fracture reduction should be exact since any residual irregularity of the articular surface will cause limited motion, delayed recovery and traumatic arthritis of the elbow.
The fracture fixation should be strong enough to allow gentle active exercises even before radiographs show evidence of complete union.
Displaced fracture olecranon causes triceps insufficiency.
The most frequent trauma is direct, due to a fall on the point of the elbow.
When it is indirect it is caused by a forcible triceps contraction.
The symptoms that you can usually feel are:
The common complications of fracture olecranon are usually late:
This is indicated for undisplaced fractures and in fractures with less than 2 mm displacement.
In children, closed reduction is done and the limb is immobilized in an above elbow plaster slab or cast for 3 to 4 weeks and this is often successful.
In adults, repair of triceps is done for avulsion fractures.
Surgery is the treatment of choice in adults.
Transverse and avulsion fractures of the olecranon and for fractures which are uncomminuted and proximal to the coronoid fossa, must be used an open reduction and internal fixation with figure of ‘8’ wire loop (on the left in the fotos below).
The medullary fixation by a single interfragmentary screw is indicated in comminuted fracture of olecranon when its distal fragment and the head of the radius are dislocated anteriorly.
Rigid fixation is required to prevent recurrence of dislocation.
Contoured plate and screws are indicated in comminuted fractures (on the right in the fotos below).
Fractures of the radial head:
Capitellum is the anterior portion of the lateral humeral condyle. This fracture is unique in being intra-articular always.
They are very common and occupy the second place in the ranking of elbow fractures.
They are complex fractures, in which the mechanism of injury involves the adjacent structures, such as the interosseous membrane of the forearm and the wrist joint (radio-ulnar joint).
The mechanism of injury is given due to a fall on an outstretched hand, with flexion or extension of the elbow and the resulting shear forces slices through the radial head breaking the capitellum.
They are fractures caused by a compressive force, transmitted longitudinally from the hand to the elbow, due to falls or violent impacts.
Based on the size of the articulating fragment, it is classified into three types:
Supination: the palm of the hand turns upwards.
Pronation: the palm of the hand turns downwards.
The forearm is made up of two long bones: the radius and the ulna.
Their rapport varies according to the state of rotation:
Forearm fractures are very common in children and are even more common than elbow fractures.
Fracture of both bones of the forearm in adults is often due to falls, assaults, etc.
The mechanism of injury is direct, for example if a nightstick hits your forearm, it may create the damage.
The mechanism of injury is indirect during traumatic events such as a fall on the outstretched hands in internal or external rotation of the wrist.
You may experience:
This type of fractures particularly affect the functionality of the limb, like the ability to fulfill the pronation and supination movements of the hand.
Treatment should first aim at anatomical reduction, to restore the normal bone physiognomy.
Undisplaced, incomplete fractures are treated by immobilization with an above elbow plaster slab or cast.
The treatment for displaced fractures consists of closed reduction by traction and counter traction methods under general anesthesia followed by an above elbow plaster cast, and is usually successful in children.
In adults open reduction with internal fixation is often indicated because it is difficult to regain length, apposition, axial and normal rotational alignment in adults by closed reduction.
Open reduction is by two approaches, one for the radius and the other for the ulna.
The choice of implants for ulna is either a medullary nail or plate and screws but for fracture radius, rigid compression plating is usually desired.
Cancellous bone grafting is done if the comminution is more than one-third of the circumference of the bone.
Wrist fractures include all those fractures of the distal portion of the radius.
On the other hand, fractures of the ulna are almost completely absent.
They rank first among all other traumatic skeletal injuries.
They are more frequently seen in males between the ages of 30 and 50; after that age, the traumatic event is more imputable to female subjects.
Wrist fractures are either extra-articular or intra-articular fractures and are classified based on the mechanism of injury.
Types: They are classified into five types namely:
Type I: Extra-articular metaphyseal fractures (E.g. Colles fracture, Smith fracture). These are caused by bending forces.
Type II: Intra-articular fractures and include Barton both dorsal and volar and Radial styloid process fractures. They are caused by shearing forces.
Type III: Intra-articular fractures and metaphyseal impaction. Radial Pilon fractures fall in this group. They are caused by compression forces.
Type IV: These are avulsion radiocarpal injuries.
Type V: Multiple comminuted fractures and are due to high velocity forces.
The causes may be due to a low-energy trauma, such as in falls, or high-energy, as occurs in road accidents or in precipitation traumas.
Based on the breakdown of the fragments, wrist fractures will look like this:
Colles fracture: the trauma is indirect, falling on the palm of the hand in a defensive posture, in extension.
It presents an alteration of the profile of the wrist, which presents a deformity defined as “fork back” and “bayonet”.
This happens because the fracture fragment of the radius moves posterior and lateral to the radius.
Goyrand’s fracture: these are much rarer fractures than Colles’s, as they occur due to falls on the hand posed in flexion.
They are called reverse Colles fractures, since, although the fracture gap is the same, the displacement of the fragment occurs in the opposite direction.
The most common symptoms you may experience are:
Wrist fractures are particularly unstable, which is why the choice between conservative and surgical therapy must be weighed on the basis of the degree of reducibility and the stability of the fracture stumps.
Treatment with cast shower should be avoided in an unstable fracture, because it forces the wrist into such an ulnar flexion and inclination, which could cause decubitus, nerve compressions, or give rise to an algodystrophic syndrome.
The indication for treatment depends on whether the fracture can be reduced with external maneuvers and whether it remains stable after reduction.
Compound fractures are treated with an antibrachio-metacarpal cast for 30 days.
In displaced fractures, an osteosynthesis is carried out using percutaneous Kirschner wires or an angular stability plate, in which the screws are screwed to the plate itself to give greater stability and reduce its immobilization times.
Fractures of the carpus and hand mainly concern the scaphoid (which holds the first place in this type of fracture, with an incidence of 75%), while fractures of the other carpal bones are rarer.
The injury occurs due to a fall on the palm of the hand or from high intensity blows with a closed fist.
Diagnosis is always very difficult, as they are small bones and their fractures are mostly compound or slightly displaced.
Compound fractures, on radiographs, can sometimes give negative results.
What you may feel is:
Complications of scaphoid injuries are:
In compound fractures, the arm is immobilized using a plaster cast that includes the forearm, wrist and hand up to the first phalanx of the first finger.
Displaced fractures require more bloody surgery and are stabilized with Kirschner wires or screws, in order to begin with joint mobilization.
Fractures that include the pelvis and lower limbs, unlike those of the upper limbs, have different healing and treatment times, both in surgery and physiotherapy.
This happens because they are bones subject to load and consequently their reduction or partial healing would compromise all the functions of the walk.
Fractures of the lower limb include all fractures of the femoral bone, knee and ankle.
Fractures of the femur occur mostly in elderly people, due to trauma of moderate energy, such as falls at home and during activities of daily living.
The main aggravating factor in the senile field is given by osteoporosis, which reduces bone mass and weakens the mechanical strength of the bone.
In particular, in the femur, it occurs more at the level of the femoral neck and the trochanteric region.
They can occur in adults, albeit more rarely, due to high-energy trauma, due to road accidents, sports, etc.
Fractures of the femur are classified according to the site of injury and are:
Fractures of the proximal femur;
Fractures of the femoral shaft.
Fractures of the proximal femur are divided into two broad categories, which based on the decomposition of the fragments, also define the severity of symptoms and complications.
When the femoral fracture is inside the joint, in medial fractures, the displacement of the bone fragments is limited by the action of the capsule and the ligaments.
On the other hand, when the fracture is outside the joint, as occurs in the lateral ones, the displacement of the bone fragments can be more serious.
Due to the action of the hip muscles (pelvitrocanterics), the most distant fracture stump is pulled upwards and rotates externally.
The innermost segment of the fracture also undergoes a rotational movement, caused by the displacement of the previous one, which provides a thrust.
The following clinical picture appears in each of the two major categories of fractures, with the exception of the lateral ones, in which the damage is greater.
What you may experience could be:
In lateral fractures of the proximal femur there will also be a situation in which the limb:
General guidelines for choosing conservative or surgical treatment in hip fractures are based on the subject’s age:
In this type of fracture, the therapy is purely surgical, but depends on whether the fracture is compound or displaced:
In compound medial fractures, osteosynthesis is performed using multiple screws or plate and screws;
In displaced medial fractures, the therapeutic approach varies according to the age and state of health of the patient:
In lateral fractures, we proceed with the reduction of the fracture and with the osteosynthesis of the bone segments using sliding screws-plates or cephalo-medullary nails.
The choice of this procedure derives from the fact that since fractures are outside the joint, necrosis of the femoral head and vicious consolidations do not appear so frequently.
Femoral shaft fracture is a serious injury and can usually be associated with severe blood loss (up to 1,500 mL), multiple fractures, and multisystem injuries.
Usually, it is due to strong violence and is common in young adults because the metaphyseal areas of the bone transmit the traumatic forces to the shaft, causing the fracture.
Male to female ratio = 3: 1
Average age of occurrence = 25-35 years
For example in adults, the most common causes are:
And in children they are due to:
In elderly patients, the metaphyseal areas are brittle and hence the shaft fracture is rare, but fracture of metaphyseal region is common.
The greatest incidence is located in the middle third of the bone structure (in the middle of the bone).
Since the fracture femur is usually due to major violence you may feel particular symptoms like:
In proximal fractures, the bone segment closest to the hip is pulled outward and forward, while the more distant segment is pulled inward to the thigh;
In distal fractures, the bone segment closest to the knee moves back and the proximal segment is pulled forward and into the thigh.
0 to 2 years: spica plaster in human position or modified Bryant or Gallows traction.
2 to 10 years: most hip fractures are observed in this age group.
Here the divided Russell traction is more useful.
From 10 to 15 years: pinstripe brace up to the hips.
More than 15 years: the treatment is the same as for adults.
In adults, skeletal traction is only useful in the initial stages and therefore its role is limited.
The average pulling time required is 12 weeks and this results in pressure complications such as pressure sores, pneumonia, kidney stones, etc.
The best method to manage a femoral shaft fracture in adults is through open reduction and internal fixation.
The choice of implants could be between a standard intramedullary nail (K-nail), an interlocking nail or a plating.
In children and adults, the surgical approach to fracture exposure is defined as fracture reduction and osteosynthesis using an external fixator:
The distal part of the femur encompasses the lower one-third.
The distal femur is subjected to the quadriceps force anteriorly and the flexion force of the gastrocnemius posteriorly.
The distal femur fracture accounts for 7 percent of all femoral fractures and consists of supracondylar fractures and intercondylar fractures.
Knee fractures are divided according to the specific injury site:
The application of high intensity axial and rotational forces on the valgus knee (internally) or varus (externally), can lead to a fracture.
The most common causes are attributable to car accidents, falls, etc.
At the time of the trauma you may experience the following symptoms:
The treatment usually consists of conservative methods, traction and operative methods.
This has a limited role and is usually useful in impacted and undisplaced fractures.
In the impacted fractures, a long leg cast is enough and in the undisplaced fractures, a long above knee cast after an initial period of skin or skeletal traction is all that is necessary.
The traction methods are mainly skeletal tractions, called upper tibial traction.
Here the skeletal traction is applied through the upper end of the tibia.
Initial weight used is around 15-20 lbs and is subsequently reduced.
The traction is given for a period of 8-12 weeks and the patient is put on cast braces.
To prevent the knee stiffness from developing, the patient is encouraged to carry out the knee movements during the traction itself.
The fixation method choice is between medullary fixation and blade plate fixation.
Intramedullary fixations: Rush pins, Ender’s nail, medullary nails, split nails, static locking nails, etc. are some of the commonly used medullary fixation methods.
External fixation is being used either for temporary or permanent fixation of these fractures in open distal femoral fractures and if associated with vascular injuries.
Patella is the largest sesamoid bone in the body.
Incidence is around 1 percent of all skeletal fractures.
Age: Common in 20-50 years age group.
Male: Female = 2: 1.
Direct trauma: this is due to dashboard injuries and due to direct fall over the patella.
They usually cause comminuted fractures, and are the common causes.
Indirect trauma: due to a quadriceps contraction.
Sudden forceful contraction of the quadriceps as in sports persons and athletes can cause patellar fractures.
Here the fracture is usually transverse and sometimes avulsion fractures of the proximal or distal poles may be seen.
The clinical picture of the subject who has suffered patellar damage is very specific for this type of fracture.
The symptoms you may experience are:
In the case in which the patellar fracture does not present a separation of the bone fragments (diastasis) or in the case of infringements, the treatment is conservative, characterized by a femoral-malleolar brace for 30 days or knee brace.
If, on the other hand, the patellar fracture does not present a clear separation of the bone fragments, the treatment is surgical.
The fracture is reduced, restoring it to the physiological state of the patient, removing the possible structures that have interposed in the fracture line.
The final operation is given by the metallic patellar cerclage and subsequent application of a knee brace for 30 days.
The tibial plateau is the part of the leg bone, the tibia, where the menisci are.
Joining with the two most distant components of the femur, the femoral condyles, it forms the large component of the knee joint.
Tibial plateau fractures are caused by falls from a height, such as falls from a horse, motorcycle, etc.
The force of injury is indirect, exerted by one or both femoral condyles, which push on the tibia, fracturing both tibial plateaus.
52% due to auto-pedestrian injuries.
17% due to fall from heights.
31% miscellaneous causes like football or soccer injuries.
What you may feel presents itself with:
As for all compound fractures, a femoral-breech brace is applied for about two months.
This has to be managed based on the time the bone and the structures require to self repair and allow the person to be able to put weight on the limb.
In displaced fractures that have undergone separation, the bone fragments are reduced and synthesized with plates and screws or even only with free screws (in the image below, left).
In depressed fractures with less than 8 mm depression, above knee cast.
For depression of more than 8 mm with a large split fragment, skeletal traction is applied.
For more than 8 mm with smaller split fragments, the open reduction internal fixation is done with bone grafting after elevation of the depression (on the right in the images below).
Tibial shaft fractures are the most common long bone fractures and they are very famous for their high incidence of open fractures.
The greatest incidence is given to children and adults.
In the elderly people, this type of fracture is the result of simple falls.
Leg fractures can include:
The mechanism of injury can be both direct and indirect:
Direct violence due to road traffic accidents (most common mode of injury), fall, assault, etc.
Open fractures are common in this mode of injury.
Indirect violence due to falls, twisting force due to sports injuries, usually cause spiral fractures.
Percentages of incidence of leg fractures:
conservative management is done in majority of cases and consists of reduction of the fracture and application of a long leg cast for 2-3 weeks, a total below knee cast which is moulded around the tibial condyles and patella in the fashion of patellar tendon bearing prosthesis is applied and movement of the knee joint and weight bearing is permitted.
Indications for the long leg cast:
Only 5 percent of the cases require operative treatment in tibial fractures.
In displaced fractures and in adults, the treatment is cruel, aimed as soon as possible to reduce and stabilize the translation of the fragments, as it is at risk of producing fat embolisms.
The elite methodology is given by internal fixation using an intramedullary nail (in the image below on the left).
In displaced and exposed fractures, external fixators find the most appropriate indication.
Ankle fractures include all those injuries that involve:
The ankles are injured due to forces from:
Ankle injuries are classified according to the mechanism that causes them.
Therefore, it is of fundamental importance to understand the movement of the ankle in order to understand its classification:
Plantar flexion and dorsiflexion are the up and down movements of the foot;
The movement that causes the toes to point inward is called internal rotation (supination) and the movement that causes the toes to point outward is called external rotation (pronation);
In adduction, the hindfoot is displaced towards the midline and in abduction it is displaced laterally.
Based on the combination of more than one of these movements, different types of fractures can be caused and consequent collateral damage to adjacent structures:
Adduction and supination:
Stage 1: fracture of the lateral malleolus (monomalleolar fracture) and / or rupture of the lateral collateral ligament;
Stage 2: stage 1 + rupture of the anterior tibio-fibular ligament + fracture of the posterior malleolus of the tibia (bimalleolar fracture);
Stage 3: Stage 2 + fracture of the medial malleolus and injury of the deltoid ligament (trimalleolar fracture).
Abduction and pronation:
Stage 1: fracture of the medial malleolus and / or rupture of the deltoid ligament;
Stage 2: stage 1 + rupture of the antero-inferior and postero-inferior tibio-fibular ligament, with fracture of the posterior malleolus of the tibia;
Stage 3: Stage 2 + oblique supralleolar fracture of the fibula.
Pronation and external rotation:
Stage 1: fracture of the medial malleolus and / or rupture of the deltoid ligament;
Stage 2: stage 1 + rupture of the antero-inferior tibio-fibular and interosseous ligament;
Stage 3: stage 2 + rupture of the interosseous membrane and spiral fracture of the fibula;
Stage 4: Stage 3 + fracture of the posterior malleolus of the tibia due to ligamentous avulsion by the postero-inferior tibio-fibular ligament.
About 75 percent of cases are in the adduction and supination movement.
The conservative method consists in the inversion of the damaging forces, through the closed reduction and the application of a plaster cast below the knee (knee-high).
The final decision is made based on the injury stability criterion:
stable injuries: No reduction is required, immobilization with only plaster splints until the swelling subsides and then a cast is applied below the knee with the foot in a neutral position.
unstable injuries: require reduction and immobilization in plaster casts, for example in fractures caused by external rotation.
The lateral malleolus is first fixed with plates or screws and then the medial malleolar fracture is fixed with a single screw perpendicular to the fracture line.
A splint is first applied below the knee and later a cast is applied.
The choice of surgical therapy depends on the site and mechanism of injury:
Fractures mainly due to abduction: They are less common than fractures caused by external rotation. However, the principles of the processing remain the same. If closed reduction fails, open reduction is preferred.
Both malleolus are fixed during open reduction.
Fracture mainly due to adduction: Wedging of small fragments in the fracture line often prevents closed reduction, requiring open reduction and internal fixation.
The medial malleolus is fixed, since it is more unstable, through osteosynthesis with two screws, one at a right angle to the tibial axis and the other at a right angle to the fracture line.
The lateral fibula fracture is stabilized with plate and screws.
Fracture mainly due to vertical compression: it can be isolated or associated with other forces described above. The anterior and posterior tibial plafond margins are fractured. Two types are described:
Posterior marginal fracture for undisplaced fracture: plaster below the knee is sufficient. For more than 25% of the joint surface involvement, external reduction with internal osteosynthesis using two screws is preferable.
Anterior marginal fracture (tibial plaque lesion): may include a squeeze of the anterior lip or may include a major fragment. If squeezed, calcaneal traction is given and if a large fragment is present, external reduction and internal fixation are required.
The talus is a bone interposed between the final portion of the tibia and the calcaneus:
Talus neck fractures are second in ranking among all ankle fractures (30%), in frequency to the chip and avulsion fractures.
On the other hand, fractures of the talus body are relatively rare.
Mechanism of injury to the talus neck:
Mechanism of injury to the body of the talus:
Complications that generally occur in talar fractures are:
The non-operative treatment of compound fractures is based on immobilization with a cast knee-high for at least 2 months.
The load on the limb is not granted for 2-3 months.
The chirurgical treatment consists in a fracture reduction and fixation with one or more screws and Kirschner wires.
Calcaneus is the most often fractured tarsal bone.
It is a ‘soft’ bone residing inside your heel doing the ‘hard’ jobs like weight transmission and locomotion.
It is a ‘small’ bone cut out for ‘big’ challenging and difficult roles.
Because of its location it is infrequently fractured, but because of its function it is a seat for many problems in life like heel pain, calcaneal spur, etc.
The unlucky few, who are more prone for calcaneal fractures are the ones who are more likely to fall from height and land on the feet like:
This type of bone lesions are classified into:
The mechanism of injury is caused by:
2. Intra-articular fractures
This type of bone trauma accounts for 60% of all tarsal injuries and 75% of all calcaneal fractures.
The mechanism of injury is purely caused by a fall from above: the talus acts as a wedge and is pushed downwards.
Pseudarthrosis is rare due to the spongy nature of the bone.
Extra-articular fractures treatment:
Fracture of anterior process:
Fracture of the tuberosity:
Fracture of the medial calcaneal process:
Fracture sustentaculum tali:
Fracture of the body that does not involve the subtalar joint: it responds well to conservative treatment.
Intra-articular fractures treatment:
The basic methods of treatment consist of:
No reduction and early motion with:
Closed reduction and fixation.
Stability of the pelvis depends on both bony and ligamentous structures.
Anterior portion of the pelvic ring neither participates in normal weight bearing nor is it essential for maintenance of pelvic stability.
The posterior arch is formed by the sacrum, sacroiliac joints and ilia and is the weight-bearing portion of the pelvis.
The postero-superior sacroiliac ligaments provide most of the ligamentous stability of the sacroiliac joints.
Fractures of the pelvis can involve all of its components:
Pelvic fractures usually occur due to high-velocity trauma following a road traffic accident or due to fall from a height.
The relative incidences are as follows:
There are four mechanisms by which pelvic ring fractures are produced:
The first two mechanisms are common in RTA and may cause stable or unstable fractures.
Vertical shear forces are due to fall from a height and will cause grossly unstable fractures.
The severe clinical picture of a person who has sustained a fracture of the pelvis is most noticeable in fractures that interrupt the pelvic girdle and are:
The patient may have all the signs of shock, which should be suspected if the following symptoms are present:
They are divided into three groups:
1. Fractures not affecting the integrity of the pelvic ring:
Direct hit fractures, which are commonly seen in the hipbone and avulsion fractures frequently seen in young people, fall into this group.
Avulsion fractures are commonly seen in the anterior-superior and inferior iliac spines and ischial tuberosity.
They are often associated with other fractures, as occurs for example in polytrauma patients.
2. Fractures affecting the integrity of the pelvic ring:
These are single or double break fractures of the pelvic ring and may be stable (resisting forces of displacement) or unstable.
They usually result in severe trauma, such as traffic accidents, falls from a height, etc.
3. Acetabulum fractures (where the femur articulates):
The third type of pelvic fractures are caused by high-energy trauma, which affects the femur distally.
1. Avulsion fracture of the:
– Anterosuperior iliac spine;
– Anteroinferior iliac spine;
– Ischial tuberosity.
2. Fracture of pubis or ischium;
3. Fracture wing of ilium,
4. Fracture sacrum.
5. Fracture or dislocation of coccyx.
These types of fractures are more complex both caused by the injury force and to the possible complications to the visceral organs.
The trauma occurs with a high-intensity damaging force that transversely approaches the two iliac wings inwards, or opening them outwards, or again vertically from above.
Acetabulum fractures occur for the most part, due to collisions of the knee against the dashboard of the car, during car accidents, and also from falls from a height, such as during some sporting gestures.
The impact force, transmitted by the head of the femur, acts on the acetabulum, fracturing it.
Pelvic fracture is a dreaded injury as it is associated with significant complications:
It is usually intra-abdominal and the incidence is about 20%.
The patient usually presents in shock.
Rupture of the urethra and rupture of the urinary bladder are the common injuries of the lower urinary tract, frequently seen in pubic symphysis fractures and rupture of the pubic tubercles.
The urethra has an average incidence of 13%, while bladder injuries are observed in 4% of cases.
80% of lesions are extra peritoneal and require direct surgery as quickly as possible.
Conservative and surgical therapy of fractures both affecting or not, the integrity of the pelvic ring:
The patient must rest in bed at least a month, with or without a cast brace (this depends on the dislocation of the fragments, which should not exceed 3 cm).
The common surgical treatment consists of reduction and stabilization through plate and screws (and in some cases with external fixation), in fractures with significant displacement of the fragments and instability.
Conservative and surgical therapy in acetabular fractures:
In compound fractures, simple bed rest is sufficient until the bone heals itself.
In pelvic injuries with femoral head dislocation, urgent treatment is required to reduce the dislocation under full anesthesia to avoid necrosis of the femur.
Femoral transcondylar traction is then applied to avoid excessive pressure between the femur and the acetabulum, and also to reduce any further dislocations.
The reconstruction of the cotyloid wall is fixed through plate and screws and then a pelvi-podal cast brace is applied.
Since bones are predisposed to the load of the body, the person who has suffered this injury cannot walk for four months.
Vertebral fractures are among the most complex in skeletal traumatology, as the spine is a structure composed of multiple anatomical compartments, and the injuries it undergoes can include very serious pictures, both at a diagnostic level and in rehabilitation, for their healing. and resolution.
Incidence of Spinal Injuries:
Man: Woman = 4: 1
The lesion is common in the cervico-thoracic and thoraco-lumbar regions.
Mechanism of injury:
Each portion of the spinal column has specific functions:
Like the skull, which protects the brain, the spinal column protects the medulla.
Spinal cord injury could cause death, quadriplegia or paraplegia.
The first distinction must be made based on the damage to the nerve roots, which, if present, also distinguishes the severity itself:
A second distinction, however, must be made based on the fracture site of the vertebra itself:
From the point of frequency and zone, vertebral fractures occur mostly in the transition zone between the thoracic and lumbar spine.
This happens because, given the vertebral mechanics, the traits are completely different:
A spine, which after the initial injury refuses to be moved further due to its intact posterior element, is called stable.
Conversely, an unstable spine is one that moves further due to severe disruption of structures that put the spinal cord at risk.
Damage to one column is stable, damage to two columns is unstable, and three columns are invariably unstable.
The unstable spine is a dangerous spine because it could injure the spinal cord.
Injuries to the cervical spine are very dangerous, if associated with neurological damage, the results can be devastating.
The two areas commonly involved in cervical spine injuries are C1-2 and C5-7.
Neurological damage occurs in 40% of cases.
In 10% of cases, radiographs are normal.
Mechanism of injury:
Types of symptoms you may experience:
Note: Symptoms appear within 48 hours of injury and 57% recover within three months. The final status is reached within one year.
It has been estimated that 6% of all fractures involving the spine, approximately 90% occur within the thoracic or lumbar region.
The vast majority of these injuries involve the segments of motion between the T11 and L2 vertebrae which include the thoraco-lumbar junction.
Thoraco-lumbar injuries occur most in men under 30 years of age and in the geriatric population.
Unfortunately, up to 20% of thoraco-lumbar fractures are accompanied by some type of neurological deficit, which corresponds to nearly 1 in 20,000 people.
The symptoms you may feel are:
In myelin fracture the clinical picture is critical and immediate.
On clinical examination, the diagnosis of the level of injury is posed by identifying the most distant functional muscle groups.
The resulting neurological damage depends on the site of injury.
In the first phase the neurological symptomatology manifests itself with:
In the second phase (beyond 10 days from the trauma) a gradual regression of symptoms may occur, which varies according to the intensity and extent of the damage.
In the event that the symptoms persist even after 10 days, an irreversibility of the neurological symptoms is to be expected.
In the case of stable fractures, without involvement of the spinal cord, the aim of the treatment is to reduce and keep the lesion reduced as much as possible, until spontaneous healing.
The methods used are generally two: the plaster cast and the orthopedic corset.
The first is used when you want to attempt a reduction of the fracture and the second when you decide to maintain the deformity of the trauma, until the bone heals.
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