Bone fractures: the complete guide

the complete guide to bone fractures

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.

Chapter 1: What is a bone fracture? How can this happen?

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:

  • Type of external and unnatural force applied to the bone;
  • Natural resistance of the bone.

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.

bone fractures symptoms

Fracture classification:

1. Bone localization:

The classification of the bone fracture can be defined by many factors.

Depending on the area of the bone involved, fractures may be:

  • Diaphyseal: the central tubular region of the bone that composes its body;
  • Metaphyseal: the region of the bone between the diaphysis and the epiphysis;
  • Epiphyseal: end part of a long bone, which forms the adjacent joint.
diaphysis-epiphysis-and-metaphysis-in-the-long-bones
  • Articular or intra-articular: when the fracture reaches the joint, it can compromise the cartilage and may create impediments to the joint movement. In that case must proceed with a fracture reduction as soon as possible;
  • Specific anatomical locations: for example the supracondylar fractures.
articular fracture and supracondylar fracture

2. Orientation and configuration of the fracture crack:

  • Transverse: occur when a bone is broken perpendicular to its axis. The crack is arranged horizontally, at right angles;
  • Oblique: the fracture line is angled, going to form an angle of less than 90 degrees;
  • Spiral: the fracture line forms a spiral along the bone segment, wrapping around it;
  • Comminute: fracture that has three or more bone fragments;
  • Multi-fragmentary: characterized by two fractured bone fragments.

3. Type of trauma:

Direct impact trauma: when the bone fractures at the point of application of the injury force:

  • Impact: they may occur by a contusion and generally manifest themselves with a transverse fracture line;
  • Meshed – bone fragments are pushed into each other, shortening the bone;
  • Compression / crushing: fractures also involve surrounding soft tissues and are generally comminuted;
  • Penetration: fractures caused by firearms, in which the bullet damages both the external and internal components.
transverse femoral shaft fracture
oblique femoral shaft fracture
spiral femoral shaft fracture
comminuted femoral shaft fracture
avulsed femoral shaft fracture
frattura da impatto e compressione del femore
greenstick femoral shaft fracture
torus femoral shaft fracture

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:

  • Traction/avulsion: these are traumatic fractures caused by a sudden and violent muscle contraction, which causes bone detachment at the tendon insertion of the muscle itself;
  • Compression/impacted: produces a spiroid fracture rim;
  • Flexion/bending: fracture that generates a transverse fracture gap;
  • Lateral cut/displacement: produces a displacement of bone fragments;
  • Torsion: This type of fracture often occurs between the vertebrae, and is caused by an impact on the soft lining of the vertebral bodies;
  • Combined force or action: it is given by the combined action of one or more forces (for example bending, rotation and compression).

4. Violence of the traumatic event:

  • High energy, as may happen during car accidents;
  • Low energy, such as an accidental fall at home or even at work.

5. Integrity of skin and soft tissues surrounding the fracture:

images about open and closed fractures
  • Closed: a fracture doesn’t damage the structures around the bone and doesn’t communicate with the external environment; the overlying skin and other soft tissues are intact;
  • Open: a fracture with a break in the overlying skin and soft tissues, leading to the fracture communicating with the external environment:

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.

6. Number of fracture foci:

  • Unifocal: there is only one outbreak of fracture;
  • Bifocal: there are two outbreaks of fracture;
  • Trifocal or plurifocal: fracture outbreaks are three or multiple, as happens in polytrauma patients.

7. Based on the extent of the fracture line:

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.

  • Complete fracture undisplaced (without dislocation of the bone fragments) in which the fracture abutments retain their position, shape and anatomical size;
  • Complete fracture displaced in which there is a loss of contact between the bone fragments (lateral displacement, longitudinal displacement, axis displacement, peripheral displacement).
incomplete and complete bone fracture

What are the aggravating factors that can cause a bone fracture:

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.

Doctor explains how osteoporosis works to an elderly man with back pain

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.

Chapter 2: What are the possible complications that can appear after a bone 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.

Immediate (acute) and late 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.

normal vein blood circulation and deep vein thrombosis (DVT)

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).

bone infection radiography

Long-term complications

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.

Consolidation delays:

The main factors are given by:

  • incomplete immobilization;
  • partial interruption of the vascular supply;
  • patient-related factors that may compromise the bone healing (for example, corticosteroids or thyroid hormones);
  • excessive separation of bone fragments;
  • movement between bone fragments;
  • presence of soft tissues between the two bone stumps;
  • an extensive lesion of the external bone cortex;
  • infection of the bone.

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.

the photo on the left shows a perfectly healthy joint cartilage and the photo on the right a cartilage destroyed by arthrosis

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.

Chapter 3: Upper limb fractures

Clavicle fractures:

clavicle fracture radiography

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.

How can you break your clavicle:

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.

What are the major sites where a fracture of the clavicle can take place:

  • The highest percentage of the fracture clavicle occurs at the junction of middle and outer third (B – 85%).
  • A very restricted percentage at the medial end of the clavicle (A – 5%).
  • Lateral end fracture is uncommon (C – 10%).
proximal, middle and distal third in clavicle fractures

How can you understand if your clavicle is broken:

The first thing you may feel is:

  • Pain;
  • Swelling;
  • Deformity and inability to raise your shoulder. 

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.

defense position a person assumes after a bone fracture

What are the complications that may come up after a clavicle fracture:

Immediate complications:

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).

Late complications:

  • pseudarthrosis;
  • vicious consolidations (visible due to a swelling on the collarbone, due to excessive callus formation);
  • vascular and nerve compressions (both structures pass behind the clavicle, moreover, after a fracture, the bone morphology can change and skeletal malunion could be “cluttered” by compressing the bundle of nerves of the brachial plexus and the subclavian vein which, both depart from the neck, reaching the extremities of the two upper limbs).

Which kind of therapies are adopted in case of a clavicle fracture:

Conservative methods:

In children (and infants) bone healing is spontaneous.

The treatment of choice in fracture clavicle consists of the following methods:

  • Cuff and collar sling for undisplaced fractures;
  • Strapping of the fracture site after reduction of the fracture by elevating the arm and bracing the shoulder upwards and backwards gives good results in both children and adults;
  • Figure of ‘8’ bandaging is popularly used and it acts by retracting the shoulder girdle, minimizes the overlap and allows more anatomical healing.
Cuff and collar sling for undisplaced fractures in adults and children

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:

  • Intramedullary fixation with K-wires;
  • Rigid plate and screw fixation with AO semi- tubular or pelvic reconstruction plate.
rigid plate and screw clavicle fixation with AO semi- tubular or pelvic reconstruction plate

Fractures of the scapula:

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.

Right scapula glenoid margin after humeral head luxation

How can you break your scapula:

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.

What are the sites of greatest frequency in scapular fractures:

Fractures of the scapula are classified according to the anatomical location:

  1. Fracture of the body of the scapula
  2. Glenoid rim and articular surface fractures
  3. Neck fractures
  4. Coracoid process fractures
  5. Acromion process fractures
  6. Spine of the scapula fractures
major areas in scapular fractures

How can you understand if your scapula is broken:

Similarly to the fractures of the clavicle, you may experience:

  • pain and swelling;
  • the damaged arm is held to the sides of the chest, in a defensive position;
  • all movements of the shoulder, especially if you try to lift your arm outwards, are painful.

What are the complications that can arise after a scapular fracture:

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.

What therapies are used case of a scapular fracture:

Conservative treatment:

Undisplaced scapular fractures may be treated conservatively with rest, sling, strap, etc.

Operative methods:

Displaced fractures need open reduction and internal fixation with K-wires, screws, etc.

Injuries of the arm

X-ray of a fracture of the humeral shaft of the left arm

Arm fractures are characterized by all those skeletal injuries affecting the humerus, the arm bone.

They are classified according to the area of injury:

  • Proximal humerus (the anatomic portion that forms the shoulder joint);
  • humeral diaphysis (body of the long bone);
  • distal humerus (final portion of the humerus, which forms the elbow joint).
distal, proximal and humeral shaft

Proximal humerus fractures:

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.

What are the sites of greatest frequency in proximal humerus fractures:

Fractures of the proximal humerus are classified into:

  • surgical neck fractures;
  • humerus trochleitis fractures (or even called large tuberosity);
  • anatomical neck fractures;
  • humeral head fractures.
sites of greatest frequency in proximal humerus fractures

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.

How to suspect a case of proximal surgical neck fracture of the humerus:

The first thing you may feel is:

  1. A lot of pain; 
  2. Swelling;
  3. Deformity and inability to move your arm. 

The main feature in this type of fracture is the blood extravasation in the arm, chest and armpit, caused by the trauma (Hennequin sign):

blood extravasation in the arm, chest and armpit, caused by the trauma called Hennequin sign

What complications can arise in case of a surgical neck proximal humerus fracture:

Immediate complications:

  • axillary artery injury;
  • axillary nerve injury, in case of fractures with luxation (when the head of the bone comes out from the joint; in that case, emergency treatment is required).

Late complications:

  • stiffness of the shoulder and elbow joint, caused by incorrect rehabilitation programs and prolonged immobilization;
  • vicious consolidations;
  • pseudarthrosis;
  • aseptic necrosis of the humeral head (cell degradation and death not due to bacterial causes).

Which kind of therapies are adopted in case of surgical neck proximal humerus fractures:

Conservative treatment:

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.

Operative treatment:

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.

Conservative treatment:

As with surgical humerus neck fractures, if the fracture is compounded, then therapy will focus on maintaining a Desault brace for 20-30 days.

Surgical treatment:

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).

Conservative treatment:

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.

Surgical treatment:

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.

Fractures of the humeral shaft (humeral diaphysis):

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.

  • If the fracture is above the insertion of the deltoid muscle, the fracture segment closest to the shoulder will be pulled forward and into the body by the force of the pectoralis major muscle;
  • If the fracture is below the insertion of the deltoid muscle, the proximal fracture fragment will be pulled up and posteriorly.

What complications may show up in case of a humeral shaft fracture:

Immediate complications:

  • the most frightening complication of humeral shaft fractures is the injury of the radial nerve, which runs along the posterior surface of the bone (image on the left). In most cases, the nerve is stretched or bruised, but it can also be completely torn. This is identifiable as the person is no longer able to extend the hand and wrist (drooping hand);
  • the brachial artery lesion: the main blood vessel of the arm;
  • the exposure of the fracture site and consequently the problems related to infections.

Late complications:

  • Pseudarthrosis (mostly due to possible muscular interpositions between the fracture stumps).

Which therapies are used in case of humeral shaft fractures:

Conservative treatment: 

This consists of immobilization of the limb with a thoraco-brachial brace for up to 3 months.

Surgical treatment:

  • in displaced fractures, in the absence of nerve injuries, the reduction of the fragments takes place by an intramedullary nail, in order to mobilize the limb as soon as possible;
  • if there is a lesion of the radial nerve, a neurorrhaphy is made, the suture of the nerve;
  • in open fractures, external fixation is mostly used.
external fixation surgery in the fracture of the humeral shaft

Elbow fractures

X-ray of a left elbow fracture

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:

  • supracondylar fractures;
  • fractures of the olecranon;
  • fractures of the radial head.
Elbow fractures areas

Supracondylar fractures:

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.

How can you suspect a supracondylar elbow fracture:

The feeling that you can experience may be:

  • gross pain, swelling and tenderness;
  • s-shaped deformity of the upper arm;
  • arm is short, forearm is normal in length;
  • dimple sign due to one of the spikes of proximal fragment penetrating the muscle and tethering the skin;
  • loss of both active and passive movements of the elbow;
  • symptoms relating to vascular and nerve injury may be seen;
  • you may also complain about some kind of pseudoparalysis.

What are the complications in supracondylar elbow fractures:

Immediate complications:

  • radial nerve injury: as it happens with humeral shaft fractures, anterior and lateral displacement of the fracture fragment can lead to nerve rupture;
  • median nerve injury (the same that is compressed in carpal tunnel syndrome) in the case of anterior and medial (inner arm) displacement; when present, the deficit presents itself in the inability to close the hand into a fist and to bring the thumb into opposition with a lack of sensitivity of the thumb, index and middle fingers;
  • humeral brachial artery injury, the largest blood vessel in the arm;
  • ulnar nerve injury (only in the rare flexion fractures);
  • Volkmann ischemic syndrome.

Late complications:

  • elbow varus, which in addition to the aesthetic disturbance, also creates functional problems of the limb, in the extension and flexion of the elbow;
  • elbow valgus, in which the deformity can be such as to lead to problems of conduction of the ulnar nerve due to its accentuation in elongation;
  • severe limitations of elbow function in extension and flexion, which occur within 30 days of injury.

What method of treatment is used in supracondylar elbow fractures:

Conservative treatment

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.

Surgical treatment:

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:

  • if there are vascular complications, to avoid ischemia, treatment must be immediate, due to the seriousness of the situation; to reduce the pressure caused by the hematoma on the artery, must proceed with the incision of the fascia that encloses the muscle (aponeurotic fascia), with a fasciotomy.
  • if the results of the bone reduction undergo in varus or valgus, a corrective osteotomy is performed.
  • if there is an excessive ulnar nerve distension, the latter is transposed anteriorly to the medial epicondyle (the bone that we can perceive at the elbow, on the inner face of the arm).
  • if Volkmann syndrome is present, the treatment in the acute phase is the removal of all encircling tight bandages, if present; when there is no improvement, the pressure within the compartment must be decompressed by fasciotomy, (the entire anterior structure of the forearm is opened, from the elbow to the wrist, through an incision).

Fracture of the olecranon:

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.

How can you break your olecranon:

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.

How can you identify a fracture of the olecranon:

The symptoms that you can usually feel are:  

  • pain; 
  • swelling; 
  • inability to extend the elbow;
  • tenderness and crepitus.

What are the complications in olecranon elbow fractures:

The common complications of fracture olecranon are usually late:

  • nonunion of the fracture;
  • osteoarthritis of the elbow;
  • triceps insufficiency;
  • restricted movements of the elbow.

What methods of treatment are used in olecranon elbow fractures:

Conservative treatment:

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.

Surgical treatment:

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).

How can you cause a radial head injury:

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.

Subdivision of radial head fractures:

Based on the size of the articulating fragment, it is classified into three types:

  • Type I: This involves a large portion of the capitellum and a small chunk of trochlea with less of subchondral portion;
  • Type II: Here only a large portion of the capitellum is involved with a huge chunk of subchondral bone;
  • Type III: Comminuted fracture.

How can you identify a radial head fracture:

  • pain on the lateral surface of the elbow;
  • pain that is accentuated by pressure;
  • pronation-supination may be impaired or nearly impossible;
  • possible compromise of the flexion-extension of the elbow.

Supination: the palm of the hand turns upwards.

Pronation: the palm of the hand turns downwards.

How radius head fractures are managed:

Conservative treatment:

  • in compound fractures, the limb is generally immobilized with a brachio-metacarpal cast brace for 20-30 days.

Surgical treatment:

  • in displaced fractures of adults, surgical treatment is performed using Kirschner wires or small screws. In case of multifragmentary fractures, the radius head is totally removed;
  • in children, the displacement consists of a detachment of the radial head; at first the surgical treatment takes place, and then the limb is immobilized through a brachio-metacarpal brace for about 20 days.

Forearm fractures:

forearm fracture radiography

The forearm is made up of two long bones: the radius and the ulna.

Their rapport varies according to the state of rotation:

  • In supination mechanism, bones are parallel to each other.
  • In the pronation mechanism, bones are crossed and the radius overlaps the ulna.

How can you cause a forearm injury:

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.

How to understand when the forearm is fractured:

You may experience:

  • severe pain; 
  • swelling and edema;
  • deformity of the forearm;
  • inability to pronate and supinate the forearm.

This type of fractures particularly affect the functionality of the limb, like the ability to fulfill the pronation and supination movements of the hand.

What are the possible complications in forearm fractures:

Immediate complications:

  • fracture exposure which can caused by high energy traumas;
  • compromission of the ulnar and radial nerve;
  • blood vessels ischemia and Volkmann ischemic syndrome.

Late complications:

  • pseudarthrosis;
  • consolidation delays;
  • vicious consolidations, which are caused by an angular or rotational deformity;
  • major limitations of the pronation-supination movements;
  • bone synostosis (when a bony bridge is created in the interosseous space between the radius and ulna, and blocks the forearm).

What methods of treatment are used in forearm fractures:

Conservative treatment:

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.

Surgical treatment:

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.

conservative treatment trough plaster cast and surgical treatment trough osteosynthesis of the bone fragments using plate and screws

Wirst fractures:

wrist fracture radiography of both radius and ulna

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.

How wrist fractures are divided:

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.

How can you cause a wrist fracture:

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.

When should you suspect a wrist fracture:

The most common symptoms you may experience are:

  • pain and swelling in the lateral region of the forearm, just below the thumb;
  • wrist movement, especially radial deviation, is painful;
  • loss of wrist function, and limited wrist movement with painful dorsiflexion; palmar flexion is also severely limited and painful.

What are the complications in wrist fractures:

Immediate complications:

  • exposure of the fracture;
  • complications of the median nerve.

Late complications:

  • vicious consolidations;
  • post-traumatic osteoporosis.

How wrist fractures are managed:

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.

Conservative treatment:

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.

Surgical treatment:

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:

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.

scaphoid fractures

How can you identify a possible fracture of the scaphoid of the hand:

What you may feel is:

    • severe pain at the base of the wrist, which often decreases, with the application of ice;
    • presence of edema and swelling;
    • pain during the palpation at the level of the anatomical snuffbox and on the first finger (extending the thumb outwards and backwards, with the back of the hand facing upwards, two long lines can be glimpsed which are enhanced by the movement of the finger; in the middle there is the anatomical snuffbox).

What can be the complications in scaphoid fractures of the hand:

Complications of scaphoid injuries are:

  • ischemic necrosis: the vascularization of the scaphoid is defined by the branches of the radial artery that penetrate inside the bone; almost all the feeding holes are found in the more distant half and therefore the proximal half receives a reduced blood supply;
  • pseudarthrosis and consolidation disorders: it is a complication that occurs between 10 and 15% of this type of fractures, which are treated with a cast. Many patients with this type of consolidation disorder experience no pain until after a subsequent trauma;
  • wrist arthrosis: as a subsequent and long-term evolution.

How radial scaphoid fractures are managed:

Conservative treatment:

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.

Surgical treatment:

Displaced fractures require more bloody surgery and are stabilized with Kirschner wires or screws, in order to begin with joint mobilization.

wrist immobilization conservative treatment with plaster including forearm, wrist and hand up to the first phalanx of the first finger

Chapter 4: Lower limb fractures

distal and proximal femur fracture shaft radiography

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.

Fracture of the femur bone:

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.

distal, proximal and femoral shaft

Fractures of the proximal femur:

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.

When should you suspect a proximal femur fracture:

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:

  • severe pain in the inguinal area, that increases with movement;
  • total limitation of the leg and its movements; walking is impossible.

In lateral fractures of the proximal femur there will also be a situation in which the limb:

  • is shortened;
  • it is placed in external rotation, with the foot completely laid on the ground.

What are the complications in proximal femur fractures:

Immediate complications:

  • anemia (anemia caused by excessive bleeding);
  • deep vein thrombosis (DVT) with pulmonary embolism;
  • pressure sores (especially at the sacral level);
  • urinary stasis.

Late complications:

  • pseudarthrosis of the femoral neck;
  • aseptic necrosis of the femoral head (phenomenon known as the nutritional supply of the arteries to the head of the femur is compromised in medial fractures);
  • vicious consolidations; in lateral fractures, over time, bone consolidation can go against varus or valgus of the femur (with mechanical stress, the neck of the femur consolidates more downwards or upwards).

How proximal femur fractures are managed:

General guidelines for choosing conservative or surgical treatment in hip fractures are based on the subject’s age:

  • In elderly subjects, the therapy is aimed at obtaining, as soon as possible, the verticalization of the subject and walking, which would be compromised due to prolonged immobilization;
  • In young subjects, the therapy is aimed at restoring the normal anatomical shape of the femur, with a greater sacrifice in the time of abstention from loading.

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 subjects <60 years, after reduction of the fragments, internal fixation is carried out using multiple screws;
  • In subjects between 60 and 75 years of age, total hip replacement is performed;
  • In subjects> 75 years of age, an endoprosthesis implant or, in some cases, partial hip replacement (surgery in which only the head of the femur is replaced) is carried out.

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.

surgical treatment in medial and lateral proximal femur fractures

Femur shaft fracture:

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.

How can you break you femoral shaft:

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:

  • road accidents;
  • Accidents at work;
  • Falls from above;
  • Gunshot wounds.

And in children they are due to:

  • Falls;
  • Birth injuries;

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).

When should you suspect a femoral shaft fracture:

Since the fracture femur is usually due to major violence you may feel particular symptoms like:

  • intense pain, which is accentuated with movement;
  • the subject is unable in any way to mobilize the limb;
  • possible exposure of the bone fragments;
    features of shock, like unconsciousness, pallor, cold nose, tachycardia, cold and clammy skin, hypotension, caused by the massive blood loss from this type of fractures;
  • leg deformity, which appears in two different ways based on where the injury occurs:

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.

What are the complications of diaphyseal fractures of the femur:

Immediate complications:

  • acute anemia and hemorrhagic shock;
  • possibility, although rare, of vascular and nerve injuries;
  • muscular interpositions between the two injured bone stumps, which can hinder the reduction of the fracture;
  • risk of developing fat embolism with acute respiratory failure (ARDS).

Late complications:

  • pseudarthrosis of the femoral neck;
  • consolidation delays;
  • vicious consolidations;
  • stiffness in the knee, caused by plaster immobilization;
  • arthritic degeneration of nearby joints (hip and knee).

what types of treatments are used in diaphyseal fractures of the femoral shaft:

Conservative treatment:

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.

Surgical treatment:

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:

fracture of the shaft of the femur osteosynthesized with plate and screws

Knee fractures:

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:

  • fractures of the distal femur (the most inferior portion of the femur, just above the patella);
  • patella fractures;
  • fractures of the tibial plateau (the body portion where the menisci rest);
  • fractures of the tibial spine.

Fractures of the distal femur (supracondylar fractures of the femur)

How can you cause a supracondylar femoral fracture:

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.

When should you suspect that you have broken your supracondylar femur:

At the time of the trauma you may experience the following symptoms:

  • pain, swelling and total inability of the leg and the knee;
  • the skeletal morphology of the knee is deformed, due to the shortening and deviation of the bone segment inwards or outwards (also called valgus or varus);
  • flexion deformity, caused by traction of the calf;
  • hemarthrosis (presence of blood, especially with fractures that extend into the joint).

Complications that can occur in supracondylar fractures of the femur:

Immediate complications:

  • vascular-nerve injuries (the nerve and vascular structures posterior to the knee);
  • exposure of the fracture.

Late complications:

  • joint stiffness in the knee;
  • arthritic degeneration, caused by the instability of the knee if it is not promptly rehabilitated.

What types of treatments are used in supracondylar fractures of the femur:

The treatment usually consists of conservative methods, traction and operative methods.

Conservative 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.

Operative methods: 

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 fractures:

X-ray of a patellar fracture

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.

How can you cause a patella fracture:

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.

When you should suspect a patellar fracture:

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:

  • swelling and swelling of the knee joint due to the spilling of blood inside the joint (hemarthrosis);
  • spontaneous pain that increases with a pressure on the bone;
  • presence of a transverse palpable space on the patellar surface;
  • you may not be able to actively extend the knee due to the interruption of the quadriceps muscle.
clinical picture of the subject who has suffered patellar damage with the presence of swelling, pain on palpation and transverse fracture rhyme

When you should suspect a patellar fracture:

Immediate complications:

  • skin changes;
  • possible association with a fracture of the cup and acetabulum, in the event that the injury occurred due to accident trauma.

Late complications:

  • pseudarthrosis of the patella (in cases where the bone fragments are not kept in contact with each other or due to lack of removal of material interposed between the fracture stumps);
  • stiffness of the knee;
  • arthrosis of the patellofemoral joint.

Which therapies are used for patella fractures:

Conservative treatment:

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.

Surgical treatment:

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.

Fractures of the tibial plateau:

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.

How can you cause a tibial plateau fracture:

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.

How can you suspect a tibial plateau fracture:

What you may feel presents itself with: 

    • pain, that increases if you try to stand up;
    • swelling from blood spilling into the joint;
    • deformity;
    • decreased movements of the knee and instability in valgus or varus;
    • pain pressure of the affected condyle (lateral to the patella internally or externally);
    • blood extravasation in the tissues (ecchymosis), down to the leg due to the gravity force;
    • angular deformity of the knee in varus or valgus (towards the outside or inside of the knee);
    • there could be features of compart- ment syndrome of the leg, disturbed peripheral vascular and nerve functions of the leg.

What are the complications that can come up in tibial plateau fractures:

Immediate complications:

  • rupture of one or more ligaments (such as medial and lateral collateral and crossed ligaments);
  • peroneal nerve palsy, which runs on the external surface of the tibia and fibula;
  • meniscal lesions.

Late complications:

  • post traumatic arthrosis;
  • varus or valgus of the knee, which could maintain this deformity, if the fracture has not been stably reduced, or for lack of it;
  • joint laxity (reduced stability of the knee) caused by the lack of suture of the ligaments injured by the trauma.

What are the most commonly used therapies in tibial plateau fractures:

Conservative treatment:

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.

Surgical treatment:

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).

Leg fractures:

right tibia fracture radiography

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:

  • isolated fractures of the tibia;
  • isolated fractures of the fibula;
  • biosseous fractures (which include both the tibia and fibula).

How can you break your leg:

The mechanism of injury can be both direct and indirect:

  • RTA: 37.5%
  • Sports: 24.7%
  • Assaults: 4.5%
  • Falls: 33.3%.

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:

  • 77% of tibial fractures are closed;
  • 23% are open fractures.

What types of symptoms you might experience after a leg fracture:

  • pain that increases if you try to stand up;
  • swelling of the leg due to blood spilling into the tissues, which often descends to the foot due to the force of gravity;
  • in case of a fibula neck fracture, the lateral popliteal nerve can be damaged and if the posterior tibial vessels are damaged too, compartment syndrome can develop.

Which kind of complications that come up after a leg fracture:

Immediate complications:

  • exposure of the fracture, which as with all bone leaks from the skin, must be identified promptly to avoid infections;
  • compartment syndrome;
  • fat embolism;
  • deep vein thrombosis and the risk of pulmonary embolism;
  • appearance of skin blisters (small blisters that appear as a result of problems related to the circulatory system and edema).

Late complications:

  • insufficient reducibility of the fracture, due to muscle flaps interposing in the fracture gap;
  • bone instability following reduction of the bone stumps;
  • nonunion and pseudarthrosis: It can be treated by electric stimulation or rigid internal fixation with compression plating and cancellous bone grafting;
  • vicious consolidations and malunion: because of the parallel hinge knee and ankle joints above and below, malunion of tibia is an unacceptable problem as it may cause early degenerative arthritis. Corrective osteotomy is the treatment of choice;
  • arthritic degeneration of the adjacent joints;
  • delayed union: if there is no evidence of union of the fracture even after 20 weeks, delayed union is suspected and is treated with cancellous bone graft;
  • infected nonunion: It is best managed by Ilizarov’s method of external fixation.
  • shortening: this may be due to malunion or overlap of the fracture fragments, less than 2 cm shortening is acceptable and may be corrected by footwear adjustments, while more than 2 cm shortening may require bone-lengthening procedures;
  • infection: due to the subcutaneous location of the bone, infection is a common complication in these fractures due to a higher frequency of compound fractures following car accidents;
  • joint stiffness;
  • re-fractures;
  • Reflex Sympathetic Dystrophy (RSD).

What kind of therapy is used for the treatment of leg fractures:

Conservative treatment:

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:

  • Most closed fractures.
  • Undisplaced fracture.
  • Fractures with minor or moderate displacements.
  • Young adults.
  • Low energy trauma.
conservative treatment in leg fractures through the application of knee-high cast

Surgical treatment:

Only 5 percent of the cases require operative treatment in tibial fractures.

Absolute Indications:

  • Tibial fracture with vascular or neural injuries;
  • Segmental fractures;
  • Inadequate reduction;
  • Associated knee problems;
  • Associated tibial plafond fracture.

Advantages:

  • Definitive form of treatment;
  • No loss of position or shortening;
  • No post fracture deformity;
  • Joint movements obtained early.

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.

External fixation surgery for a tibial fracture

Ankle fractures:

X-ray of ankle fracture trauma with osteosynthesis with fibula plate and screws

Ankle fractures include all those injuries that involve:

  • the neck of the foot: medial and / or lateral malleolus and the third malleolus;
  • the bones of the foot: talus, calcaneus, tarsal and metatarsal bones.

Incidence factors:

  • Most commonly in older women;
  • About 2/3 are isolated malleolar fractures;
  • About 1/4 are bimalleolar fractures;
  • Trimalleolar fractures are seen only 7%;
  • Open fractures 2%.

How can you cause an ankle fracture:

The ankles are injured due to forces from:

  • twisting during walking, running, sport, etc .;
  • fall from a height: in this case the ankle injuries are caused by indirect forces caused by the displacement of the talus.

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.

What types of symptoms you might experience after an ankle fracture:

  • pain that increases with active and passive mobilization of the ankle, which varies according to the number of bone lesions;
  • inability to load on the limb;
  • bone deformity of the region affected by the trauma, with deviation of the foot;
  • the limb is swollen and swollen due to blood extravasation in the tissues.

What are the complications that can come up in ankle fractures:

Immediate complications:

  • exposure of the fracture;
  • vascular disorders may occur in dislocations;
  • lesions of the internal vascular nerve bundle of the ankle (anterior tibial artery, peroneal nerve);
  • lesion of the capsule-ligamentous compartment;
  • tendon injury of the posterior tibialis muscle;
  • lesions of the cartilage of the talus that articulates with the distal portion of the tibia.

Late complications:

  • post-traumatic arthrosis;
  • stiffness of the ankle joint (which allows the foot to be extended and flexed);
  • Sudek syndrome;
  • pseudarthrosis of the malleoli;
  • vicious consolidations;
  • instability of the ankle joints.

What kind of therapy is used for the treatment of ankle fractures:

Conservative therapy:

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.

Surgical therapy:

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.

Talus fractures:

The talus is a bone interposed between the final portion of the tibia and the calcaneus:

  • participates in weight transmission;
  • has a precarious blood supply;
  • 3/5 of the bone is covered with articular cartilage;
  • sudden hyperextension of the forefoot causes neck fracture.

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.

How can you cause a talus fracture:

Mechanism of injury to the talus neck:

  • the common mode of injury is hyper-dorsiflexion of the foot on one leg;
  • it may be associated with fracture of the tarsal bones and fracture of the metatarsal bones;
  • previously, it was most commonly seen in flight accidents, but it also occurs in road accidents due to a frontal collision.

Mechanism of injury to the body of the talus:

  • usually due to a fall from a height;
  • it can be associated with fractures of the malleolus.

What types of symptoms you might experience following a talus fracture:

  • pain and swelling of the ankle;
  • deformity in displaced fractures;
  • the skin may be kinked or stretched.

What are the complications that can come up in talar fractures:

Complications that generally occur in talar fractures are:

Immediate complications:

  • vascular-nerve problems, which can be seriously compromised in ankle dislocations.

Late complications:

  • ischemic aseptic necrosis of the talus, due to lack of nutritional supply;
  • subtalar joint arthrosis (the joint between the talus and the calcaneus);
  • ankle arthrosis (the joint between the talus and the tibia);
  • joint stiffness in the ankle.

Which type of therapy is mostly used for the treatment of talar fractures:

Conservative treatment:

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.

Surgical treatment:

The chirurgical treatment consists in a fracture reduction and fixation with one or more screws and Kirschner wires.

Fractures calcaneum:

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:

  • construction workers of high rise buildings;
  • electrical and telephone linemen working at the top of the poles;
  • casual laborers engaged in plucking the tender coconuts from the lanky coconut trees;
  • athletes involved in high jump and long jumps etc;
  • thieves who jump down the houses, after burglary to escape being caught by the police.

How can you cause a talus fracture:

This type of bone lesions are classified into:

  1. Extra-articular fractures

The mechanism of injury is caused by:

  • torsional forces;
  • fall from a height, landing on the heels.

Incidence factors:

  • Bilateral fractures are observed in 5-9% of cases;
  • 10% of cases present damage to other anatomical structures, for example, fractures of the dorsal or lumbar vertebral bodies due to compression;
  • 26% are associated with other lower limb injuries.

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.

What types of symptoms you might experience following a talus fracture:

  • heel pain and swelling; 
  • inability to bear the weight of the body, stand or walk;
  • pain during supination and heel pronation;
  • lateral heel compression causes severe pain;
  • heel widening, looking posterior to the ankle;
  • horseshoe swelling on both sides of the Achilles tendon;
  • the distance between the heel and the malleolus is reduced.

What are the complications that can arise in talar fractures:

Pseudarthrosis is rare due to the spongy nature of the bone.

  • bone nonunion is the most common complication;
  • heel pain: The source of heel pain could be from:
  1. post-traumatic osteoarthritis;
  2. peroneal tendonitis due to stenosing tenovaginitis of the fibular tendons;
  3. bone spurs due to malunion of the fracture and rupture of the fat pad of the heel;
  4. arthrosis of the calcaneus-cuboid joint;
  5. nerve entrapment is rare.

What type of therapy is used for the treatment of talar fractures:

Extra-articular fractures treatment:

Fracture of anterior process:

  • avulsion fracture: short leg cast;
  • compression fracture: reduction and fixed with Kirschner wire or screws.

Fracture of the tuberosity:

  • undisplaced fracture: short leg cast;
  • displaced fracture: open reduction and internal fixation.

Fracture of the medial calcaneal process:

  • undisplaced fracture: plaster cast;
  • displaced fracture: open reduction and internal fixation.

Fracture sustentaculum tali:

  • undisplaced fracture: plaster cast;
  • displaced fracture: open reduction and casting.

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:

  • application of bandages;
  • foot elevation;
  • weight bearing at the end of 12 weeks.

Closed reduction and fixation.

Chapter 5: Fractures of the pelvis

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:

  • Ilium;
  • Ischium;
  • Pubis;
  • Sacrum;
  • Coccyx.

How can you break your pelvis:

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:

  • RTA 80.7%;
  • fall 16.1%;
  • compression fracture 3.2%.

There are four mechanisms by which pelvic ring fractures are produced:

  • lateral compression;
  • anteroposterior compression;
  • vertical shears forces;
  • inferior forces (e.g. fall on buttocks).

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.

Which types of symptoms you might experience after a pelvis fracture:

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 lower limb of the affected side is kept motionless, by the intensity of the pain;
  • it is possible to observe an asymmetry of the iliac crests, with a difference in the length of the lower limbs;
  • massive blood loss, which worsens the more the fracture fragments have been broken down.

The patient may have all the signs of shock, which should be suspected if the following symptoms are present: 

  • pale look;
  • cold nose;
  • sweating;
  • tachycardia;
  • hypotension;
  • cold and clammy skin;
  • unconsciousness.

What types of pelvic fractures can occur:

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.

Fractures not affecting the integrity of the pelvic ring:

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.

Mechanism of injury in fractures not affecting the integrity of the pelvic ring:

  • In fractures of the tuberosity of the iliac spine the injury occurs by avulsion, caused by abrupt muscle contractions. The greatest incidence is attributed to children, who, compared to adults, are still in the phase of bone growth;
  • In isolated fractures of the ischium, the injuries are caused by low intensity trauma, in people suffering from osteoporosis and the bone can easily break;
  • Transverse fractures of the sacrum and coccyx result from direct trauma.

Fractures affecting the integrity of the pelvic ring:

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:

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.

When should you suspect an acetabular fracture:

  • you may feel a very intense pain and the absolute inability to move the leg;
  • the more the leg was kept in flexion at the moment of the trauma, the higher the risk of posterior dislocation of the femur;
  • in posterior fractures the limb is shorter than the other, the leg is bent and internally rotated;
  • in anterior fractures the leg is bent and externally rotated;
  • local pain that increases upon palpation of the femur and any movement of the leg.

What are the complications in pelvic fractures:

Pelvic fracture is a dreaded injury as it is associated with significant complications:

  • Hemorrhage:

It is usually intra-abdominal and the incidence is about 20%.

The patient usually presents in shock.

  • Lower urinary tract lesions:

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.

  • Testicular injuries and vaginal lacerations, intestinal, rectal injuries, and urethral injuries are all common and require immediate surgery;
  • loss of reduction;
  • sepsis;
  • thrombophlebitis;
  • delayed union;
  • pseudarthrosis;
  • post-traumatic arthritis;
  • fat embolism;
  • major arterial injuries;
  • abdominal wall injury;
  • neurological injury of L5;
  • S1 roots due to sacral fracture are the other common complications.

Which therapies are used in pelvic fractures:

Conservative and surgical therapy of fractures both affecting or not, the integrity of the pelvic ring:

Conservative therapy:

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).

Surgical therapy:

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:

Conservative therapy:

In compound fractures, simple bed rest is sufficient until the bone heals itself.

Surgical therapy:

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.

Chapter 6: Vertebral fractures

compression vertebral fracture radiography

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:

  • road accidents: 45%;
  • falls: 20%;
  • sports injuries (diving): 15%;
  • acts of violence: 15%.

Each portion of the spinal column has specific functions:

  • the cervical spine provides the head with limited mobility and protects the proximal part of the spinal cord;
  • the thoracic spine provides mobility to the upper torso and rib cage and protects the medulla;
  • the lumbar spine provides for the lower part of the torso, its mobility and protects the medulla.

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:

  • myelinated fractures: these include vertebral fractures, involving the spinal cord and / or nerve roots.
  • unmyelinated fractures: isolated fractures of the vertebrae, without involvement of the spinal cord or any nerve bundles.

A second distinction, however, must be made based on the fracture site of the vertebra itself:

  • anterior column: includes the anterior part of the vertebral body, the disc and the anterior longitudinal ligament;
  • intermediate column: includes the posterior part of the vertebral body and disc, posterior longitudinal ligament;
  • posterior column: includes all the components posterior to the vertebral body (the joints between the vertebral bodies, the vertebral processes, ligaments, etc.).

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:

  • the cervical spine has a particular susceptibility to traumatic injuries as they have a smaller structure than the dorsal and lumbar tract, and must bear considerable muscle and head weight;
  • the thoracic spine is more rigid, as it is more constrained by the relationship with the rib system;
  • the lumbar spine is very mobile, the vertebrae have a body that can support the load and weight of the body more, but it is also the stretch where the greatest stresses occur.

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.

Fractures of the cervical spine:

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.

How can you cause a fracture of the cervical vertebrae:

  • fall from above: it is the most common cause in developing countries;
  • underwater injuries: diving in water with insufficient depth or in a state of intoxication;
  • road accidents: common cause in developed countries, eg. whiplash injury;
  • gunshot injuries, directly injure the cervical spine and spinal cord.

Mechanism of injury:

  • pure bending force: compression fracture of the vertebral body, e.g. falling from above onto a step;
  • rotational force of flexion: a fall on one side of the shoulder leads to a possible injury to the capsule of the facet joint of the vertebra;
  • axial compression: the fall of an object on the head causes a compressive force of the vertebrae;
  • extension force: for example, avulsion fracture of the upper edge of the vertebral body, eg. flick;
  • lateral flexion: for example fracture of the pedicle, fracture of the transverse process and of the articular facets, etc .;
  • direct injuries: for example, fracture of the spinous process and body due to assaults, gunshot wounds, etc.

When should you suspect a cervical spine injury:

Types of symptoms you may experience:

  • pain and swelling in the upper neck that gets worse with movement; 
  • pain that increases if pressure is applied to the spinous process of the fractured vertebra (the small bone that can be felt when pressing on the spine with the fingers), and a defensive muscle contracture;
  • occipital headache;
  • stiff neck;
  • rarely dizziness, auditory or visual disturbances, etc .;
  • decreased range of motion in the neck;
  • muscle spasm of the neck is observed;
  • there may be signs of neurological involvement.

Note: Symptoms appear within 48 hours of injury and 57% recover within three months. The final status is reached within one year.

Fractures of the dorsal and lumbar spine:

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.

How can you cause a fracture of the dorsal and lumbar spine:

  • in younger patients, these fractures usually result from high-energy blunt trauma such as car accidents, falls from heights, and sports-related injuries;
  • gunshot wounds, assaults, etc .;
  • eue to their low bone density and cognitive impairment, older adults are also at risk of these fractures after a fall from a standing position and other minor traumatic episodes.

When you should suspect a dorsal and lumbar spine injury:

The symptoms you may feel are:

  • severe pain that increases with the palpation of the painful thorny and possible presence of a step;
  • presence of back swelling;
  • neurological involvement can range from paraplegia to individual nerve root involvement.
pain felt in fractures of the dorsal and lumbar spine

What are the complications in vertebral fractures:

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:

  1. Flaccid paralysis of the limbs (paraplegia)
  2. Absence of reflexes;
  3. More or less widespread anesthesia (absence of sensitivity);
  4. Paralysis of the sphincters.
  5. Shock.

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 myelinated lesions from the cervical tract between C1 and C4 there are complete breathing, motor and sensory alterations from the neck down throughout the rest of the body; in this case the patient’s death occurs even before arrival at the hospital;
  • in myelinated lesions between C5 and C8 breathing is superficial, the general picture consists of motor and sensory alterations of the four limbs (tetraplegia and tetranesthesia) and urinary retention (the inability to completely empty the bladder);
  • in the myelinated lesions of the lumbar tract (D / T 12 – L1 up to the cauda equina), sensory-motor deficits in the lower limbs and bladder incontinence are present;
  • in the myelinated lesions of the lumbar tract (D / T 12 – L1 up to the cauda equina), sensory-motor deficits in the lower limbs and bladder incontinence are present;
  • paraplegia caused by spinal cord injury can cause bedsores, cysts and cystopyelitis, edema and thrombophlebitis, bronchopulmonary infections;
  • degenerative disc disease, which generally arises in fractures of the vertebral body, which is very conditioned by the size of the disc, for its healing.

What treatments are mostly used in vertebral fractures:

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.

  • In fractures of the anterior column, the fracture is reduced and a cast is applied to immobilize the structures, for a duration of about 40 days;
  • in intermediate spine fractures, the principles of treatment of the anterior one are adopted, also for 30-40 days;
  • in posterior vertebral fractures, the spine is immobilized by means of a rigid brace and splint for about 20 days;
  • in total fractures, to avoid neurological compromises, the subject is kept immobilized with a brace for three months, until the vertebra has completely healed;
  • in bone marrow impact fractures, surgical therapy is performed if the neurological damage is caused by the dislocation of a bone fragment or by the reduction of the medullary canal (stenosis);
  • in degenerative discopathies, osteosynthesis of the two vertebrae can be proceeded through arthrodesis (a surgical operation in which two bones are joined with or without the insertion of an implant, such as screws, bars, plates, etc.).
vertebral arthrodesis surgery radiography

2 Comments

  • Thanks for your blog, nice to read. Do not stop.

    • Marco Castenetto

      Thanks Mark! Surely not, I’m ready soon with another article!

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