A fracture is a break, usually in a bone. If the broken bone punctures the skin, it is called an open or compound fracture. Fractures commonly happen because of car accidents, falls, or sports injuries. Other causes are low bone density and osteoporosis, which cause weakening of the bones. Overuse can cause stress fractures, which are very small cracks in the bone.

Symptoms of a fracture are

• Intense pain
• Deformity - the limb looks out of place
• Swelling, bruising, or tenderness around the injury
• Numbness and tingling
• Problems moving a limb

You need to get medical care right away for any fracture. An x-ray can tell if your bone is broken. You may need to wear a cast or splint. Sometimes you need surgery to put in plates, pins or screws to keep the bone in place.

Fractures are classified by their complexity, location, and other features. Some fractures may be described using more than one term because it may have the features of more than one type (e.g., an open transverse fracture).

Metacarpal fractures account for 40% of all hand fractures. A Boxer’s fracture is a fracture of the fifth metacarpal neck, named for the classic mechanism of injury in which direct trauma is applied to a clenched fist.  This represents 10% of all hand fractures. Treatment for a Boxer’s fracture varies based on whether the fracture is open or closed, characteristics of the fracture including the degree of angulation, shortening, and rotation, and other concomitant injuries. Immobilization with an ulnar gutter splint may be the definitive treatment for closed, non-displaced fractures without angulation or rotation, while open fractures, significantly angulated or malrotated fractures or those involving injury to neurovascular structures may require operative fixation.

Treatment / Management

The appropriate treatment for a Boxer’s fracture on initial presentation varies based on whether the fracture is open or closed, the degree of angulation, rotation, and other concomitant injuries. Due to the risk of infection from "fight bite," even very small wounds should be thoroughly irrigated, and there should be a low threshold for antibiotic treatment.

Immobilization Alone

For a Boxer’s fracture that is closed, not angulated, and not malrotated or otherwise displaced, splinting is used for initial immobilization. A Boxer’s fracture should be immobilized with an ulnar gutter splint. Alternatively, a pre-made Galveston splint or a custom orthosis may be used.

The hand should be positioned in the intrinsic plus position for splinting: mild wrist extension, 70 to 90 degrees of flexion at MCP joint, and slight flexion at the DIP and PIP joints. Flexion of these joints is important to prevent shortening of the collateral ligaments and subsequent loss of range of motion and functional impairment.

Closed Reduction

Closed reduction is required for a Boxer’s fracture with significant angulation greater than 30 degrees.

Analgesia options for the procedure include a hematoma block or an ulnar nerve block. Younger children or very anxious patients may require procedural sedation, but this procedure typically is tolerated well without sedation.

Closed reduction of a Boxer’s fracture is accomplished by using the “90-90 method.” The MCP, DIP, and PIP joints should all be flexed to 90 degrees. The clinician should then apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint. This axial pressure to the PIP applies dorsal force to the distal fracture fragment. The clinician should be able to feel the reduction when it has been achieved. The injury should be immobilized with an ulnar gutter splint, and post-reduction films should be taken to assess for adequate reduction. The fifth metacarpal neck can tolerate angulation of up to 50-60 degrees and management may be continued non-operatively if remains within the acceptable tolerances.

Surgical Referral

Surgical referral is indicated for fractures that are open, severely comminuted, associated with neurovascular injury, and for fractures with any malrotation. Surgical referral is also appropriate for fractures with significant angulation if the initial provider is unsuccessful in achieving adequate reduction and alignment outside acceptable parameters.  Surgical options include open reduction internal fixation, or closed reduction percutaneous pinning. 

Follow-Up

Boxer’s fractures should be sent for repeat radiographs within one week to assess alignment. Radiographs should be obtained every two weeks following, until clinical and radiographic healing are present, typically between four to six weeks. Even with the adequate reduction, some cosmetic deformity may persist, with loss of the normal knuckle contour. After a short period of immobilization, the passive and active range of motion exercises should be performed to alleviate stiffness of the MCP and PIP joints. Literature supports early mobilization of these injuries rather than prolonged immobilization. If any loss of function persists after several weeks of these exercises, referral to occupational therapy is warranted.

The nasal bone is one of two small bones that articulate (join) with each other to form the bony base (bridge) of the nose. They also support the cartilages that form the lateral walls of the nose (see Figure 7.11). These are the bones that are damaged when the nose is broken.

Figure 7.11 Sagittal Section of Skull This midline view of the sagittally sectioned skull shows the nasal septum.

Fractures involving a GROWTH PLATE.

Knee Fractures

Fractures of bones at the KNEE and the KNEE JOINT.

Hoffa Fracture

Coronal plane fractures of the FEMUR condyle at the KNEE.

Patella Fracture

Fractures of the PATELLA.

Tibial Plateau Fractures

Fractures in the proximal portion of the TIBIA which acts as articular surface in the KNEE. They are often associated with knee ligament injuries (e.g., ACL TEARS).

A fracture of the shaft of the ulna associated with an anterior dislocation of the radial head was described by an Italian surgeon, Giovanni Battista Monteggia, in 1814. This injury pattern was eponymously named as the Monteggia fracture-dislocation by Perrin in 1909. In 1958, Jose Luis Bado, a professor of orthopedic surgery from Uruguay, elaborated on the pathomechanics and management of this fracture-dislocation in a monograph that was first published in Spanish then later in English. He introduced the concept of a Monteggia lesion and Monteggia equivalent injuries. Bado included a group of injuries having in common a dislocation of the radial head associated with fractures at various levels of the ulna or with injuries at the wrist.

The evolution of management of Monteggia fracture-dislocations can be considered in 3 chronological periods. In the early period (1814–1939), the components of the Monteggia injury were identified, and the importance of reducing the radial head and ulna shaft fracture became apparent. In the intermediate period (1940–1990), the availability of implants made open reduction and internal fixation of the ulna shaft possible. There was also an increased awareness of the mechanism of the injury and variations of the original injury, namely the Monteggia lesion and its equivalents. In the current period (1991 and onwards), better results have been obtained as a result of prompt recognition of the injury and improved plate fixation techniques that have allowed anatomic reduction of the ulna and restoration of normal contour of the trochlear notch.

Appendicular System: Fractures of Upper Limb Bones

Due to our constant use of the hands and the rest of our upper limbs, an injury to any of these areas will cause a significant loss of functional ability. Many fractures result from a hard fall onto an outstretched hand. The resulting transmission of force up the limb may result in a fracture of the humerus, radius, or scaphoid bones. These injuries are especially common in elderly people whose bones are weakened due to osteoporosis.

Falls onto the hand or elbow, or direct blows to the arm, can result in fractures of the humerus. Following a fall, fractures at the surgical neck, the region at which the expanded proximal end of the humerus joins with the shaft, can result in an impacted fracture, in which the distal portion of the humerus is driven into the proximal portion. Falls or blows to the arm can also produce transverse or spiral fractures of the humeral shaft.

In children, a fall onto the tip of the elbow frequently results in a distal humerus fracture. In these, the olecranon of the ulna is driven upward, resulting in a fracture across the distal humerus, above both epicondyles (supracondylar fracture), or a fracture between the epicondyles, thus separating one or both of the epicondyles from the body of the humerus (intercondylar fracture). With these injuries, the immediate concern is possible compression of the artery to the forearm due to swelling of the surrounding tissues. If compression occurs, the resulting ischemia (lack of oxygen) due to reduced blood flow can quickly produce irreparable damage to the forearm muscles. In addition, four major nerves for shoulder and upper limb muscles are closely associated with different regions of the humerus, and thus, humeral fractures may also damage these nerves.

Another frequent injury following a fall onto an outstretched hand is a Colles fracture (“col-lees”) of the distal radius. This involves a complete transverse fracture across the distal radius that drives the separated distal fragment of the radius posteriorly and superiorly. This injury results in a characteristic “dinner fork” bend of the forearm just above the wrist due to the posterior displacement of the hand. This is the most frequent forearm fracture and is a common injury in persons over the age of 50, particularly in older women with osteoporosis. It also commonly occurs following a high-speed fall onto the hand during activities such as snowboarding or skating.

The most commonly fractured carpal bone is the scaphoid, often resulting from a fall onto the hand. Deep pain at the lateral wrist may yield an initial diagnosis of a wrist sprain, but a radiograph taken several weeks after the injury, after tissue swelling has subsided, will reveal the fracture. Due to the poor blood supply to the scaphoid bone, healing will be slow and there is the danger of bone necrosis and subsequent degenerative joint disease of the wrist.

Etiology

As high as 80-90% of all scapular fractures occurred during high-energy trauma such as motor vehicle collisions, falls, and other high impact trauma. Direct force may cause fractures of any region of the scapula while impaction of the humeral head into the glenoid fossa is often responsible for scapular neck and glenoid fractures. Motor vehicle collisions account for over 70% of scapular fractures, with 52% associated with drivers and 18% associated with pedestrians struck by motor vehicles. Other reported mechanisms include electric shock and seizure because of forces on the scapula. Isolated scapular fractures are rare.

Epidemiology

Scapular fractures account for approximately 0.4-1% of all fractures, 3% of all fractures of the shoulder, and 5% of all fractures of the shoulder girdle. Scapular fractures preferentially occur in young males (M: F = 6:49) between the ages of 25 and 50 years old and most often occur in the body or the glenoid.

• Body: 45%

• Glenoid Process: 35%

• Acromion: 8%

• Coracoid: 7%

Pathophysiology

Anatomy

The scapula, more popularly known as the shoulder blade, is the bone that connects the clavicle to the humerus. It is a triangular shape with four major processes: the spine, the acromion, the coracoid process, and the glenoid process: the scapula functions as the attachment site for 18 muscles which connected to the thorax, spine, and upper extremity. The scapula, besides the clavicle and humerus, provides rotational movement of the upper extremity and assist with abduction and rotation at the glenohumeral joint.

Pathophysiology

Due to the force required to fracture of the scapula, there is a wide variety of fracture patterns reported. Fractures are classified based on the anatomical location on the scapula with fracture occurred. The Orthopedic Trauma Association has proposed a classification system at two levels: level 1 as a basic system for all trauma surgeons and level 2 for specialized shoulder surgeons. While this classification system is useful for classifying scapular fractures to identify the appropriate follow-up, no studies have correlated the grading system with prognosis.

History and Physical

The most common mechanism is blunt or penetrating trauma directly to the scapula. The physical exam and history can give the physician pertinent information and help rule out associated injuries that can be life-threatening. In a high energy trauma situation, depending on the patient's mental status this is not always possible. The physical exam of the shoulder and upper extremity should be performed in a matter that allows examination of the posterior forequarter. This can be difficult when the patient has multiple injuries and is supine in bed. Asymmetry of displacement of the shoulder or humeral head can be obvious or subtle. Palpation and visual examination of the bony landmarks should be performed followed by a thorough neurovascular examination of the upper extremity. Brachial plexus injuries can be associated with scapula fractures in 5-13 percent of patients. Motor function can be difficult to assess secondary to pain associated with these injuries. A full assessment of the skin to look for open fractures is prudent because open fractures of the scapula require immediate irrigation and debridement in addition to antibiotics.

Evaluation

Because of the high energy needed to fracture the scapula, most patients found to have fractures of the scapula will have multiple other injuries. The patient should undergo evaluation as a trauma patient. However, there are specific potentially life-threatening injuries associated with scapular fractures that require assessment. For example, thoraco-scapular dissociations with disruptions of the subclavian vein and axillary vessels can lead to life-threatening hemorrhage.

Diagnostic imaging should be performed to evaluate both scapular fractures and associated trauma. While conventional radiographs including an anterior-posterior, lateral, and axillary views are sufficient for evaluation of most scapular fractures, conventional radiography often misses associated injuries. Therefore, the recommendation is that a CT scan is performed in the evaluation of scapular fractures. If there is a concern for the involvement of a joint, MRI may be needed to evaluate for ligamentous injury. 3D reconstruction of CT imaging may be helpful in determining management approaches and the need for surgical intervention.

A hangman’s fracture is better described as bilateral fracture traversing the pars interarticularis of C2 with an associated traumatic subluxation of C2 on C3. It is the second most common fracture of the C2 vertebrae following a fracture of the odontoid process and is almost always stable without the need for surgical intervention. Steele’s rule of thirds states that the cross-sectional area at the level of the atlas may be divided into three equally represented parts: the dens, space, and the spinal cord. This increased area for the spinal cord at this level is what allows for the relative lack of neurologic injury associated with a hangman’s fracture.

Fractures of the femur.

Fractures: Bone Repair

A fracture is a broken bone. It will heal whether or not a physician resets it in its anatomical position. If the bone is not reset correctly, the healing process will keep the bone in its deformed position.

When a broken bone is manipulated and set into its natural position without surgery, the procedure is called a closed reduction. Open reduction requires surgery to expose the fracture and reset the bone. While some fractures can be minor, others are quite severe and result in grave complications. For example, a fractured diaphysis of the femur has the potential to release fat globules into the bloodstream. These can become lodged in the capillary beds of the lungs, leading to respiratory distress and if not treated quickly, death.

Types of Fractures

Fractures are classified by their complexity, location, and other features (Figure). Table outlines common types of fractures. Some fractures may be described using more than one term because it may have the features of more than one type (e.g., an open transverse fracture).

Bone Repair

When a bone breaks, blood flows from any vessel torn by the fracture. These vessels could be in the periosteum, osteons, and/or medullary cavity. The blood begins to clot, and about six to eight hours after the fracture, the clotting blood has formed a fracture hematoma (Figurea). The disruption of blood flow to the bone results in the death of bone cells around the fracture.

Within about 48 hours after the fracture, chondrocytes from the endosteum have created an internal callus (plural = calli) by secreting a fibrocartilaginous matrix between the two ends of the broken bone, while the periosteal chondrocytes and osteoblasts create an external callus of hyaline cartilage and bone, respectively, around the outside of the break (Figureb). This stabilizes the fracture.

Over the next several weeks, osteoclasts resorb the dead bone; osteogenic cells become active, divide, and differentiate into osteoblasts. The cartilage in the calli is replaced by trabecular bone via endochondral ossification (Figurec).

Eventually, the internal and external calli unite, compact bone replaces spongy bone at the outer margins of the fracture, and healing is complete. A slight swelling may remain on the outer surface of the bone, but quite often, that region undergoes remodeling (Figured), and no external evidence of the fracture remains.

Vertebral compression fractures (VCFs) of the spinal column occur secondary to an axial/compressive (and to a lesser extent, flexion) load with resultant biomechanical failure of the bone resulting in a fracture. VCFs by definition compromise the anterior column of the spine, thereby resulting in compromise to the anterior half of the vertebral body (VB) and the anterior longitudinal ligament (ALL). This leads to the characteristic wedge-shaped deformity.

VCFs do not involve the posterior half of the VB and do not involve the posterior osseous components or the posterior ligamentous complex (PLC). The former distinguishes a compression fracture from a burst fracture. The implications of these compression fractures are related to the stability of the resulting structure and potential for deformity progression. Compression fractures are usually considered stable and do not require surgical instrumentation.

Ankle Fracture (Broken Ankle)

An ankle fracture is a break of the ankle bones.

PubMed Health Glossary (Source: Wikipedia)

About Ankle Fractures

When people twist their ankle they might sprain it. This means that muscles and soft tissue around the ankle joint are injured. But sometimes the ankle joint is fractured (broken) instead. This is a more serious injury that may affect one or more bones in your ankle. If the ankle joint is fractured, the ligaments are often torn and cartilage damaged too. The foot becomes swollen, is painful and can no longer hold any weight.

Outlook

It takes several days or weeks for the swelling to go down completely, and can take months for the ankle joint to fully recover from the fracture. Until then, the foot cannot be moved much and cannot carry much weight.

If the healing process is disturbed too soon and the fracture does not heal properly, other treatments may be needed. On the other hand, if a person does not move their foot for a long time, it could become less mobile and weaker.

Diagnosis

The doctor will probably first ask how the accident happened, and then examine the foot and ankle to see how severe the injury is. If he or she suspects that the ankle is fractured, an x-ray of the ankle is taken. Sometimes x-rays do not lead to a clear diagnosis. Then a computed tomography (CT) scan, and perhaps also a magnetic resonance imaging (MRI) scan, might be done too. Ligament and cartilage injuries can usually be seen better with MRI scans.

Treatment

Surgery is usually not needed for ankle fractures. Whether or not surgery is done depends on various factors, including how bad the fracture is, where the ankle is fractured, and whether the bone fragments are in the right place. Screws or plates might be used to hold bone fragments in place so they can grow together again. After surgery the ankle will be immobilized (kept still) using a brace, splint or plaster cast. Some braces and splints are removable, making it possible to already start doing gentle exercises during the immobilization phase.

Even if surgery is not needed, the foot and ankle are still immobilized at first in order to protect the joint and avoid disturbing the healing process. Braces, splints or plaster casts are generally used for around six weeks. After a while you can gradually start putting more strain on the joint and strengthening it. The point at which people are advised to start doing gentle exercises or physiotherapy depends on things like how bad the injury is: Some already start a few days after the injury or surgery, and others only start when their splint or plaster cast comes off.

Rib fractures occur when a significant enough force directed at the rib causes a break. There are a total of 12 pairs of ribs in the thoracic region. The first seven ribs attach anteriorly to the sternum and posteriorly to the spinal column. Rib numbers 8 through 10 attach similarly but connect to the costal cartilage of the sternum anteriorly. Ribs 11 and 12 have the name of “floating” ribs as they only attach posteriorly but do not attach anteriorly. Underneath each rib lies the intercostal nerve, artery, and veins which supply to blood supply and innervation. The ribs function to protect the underlying organs and structures of the thoracic cavity. Any rib fracture should warrant a thorough evaluation of any concomitant injury, including lungs, heart, kidney, spleen, liver, and neuro-vasculature.

The patella is the largest sesamoid bone in the human body. The posterior aspect of the patella contains a thick cartilage layer, which is the thickest cartilage in the body. A vertical ridge separates the medial and lateral facets of the articular surface and articulates with the femoral trochlea. The patella protects the anterior aspect of the knee joint, serves as the insertion for the quadriceps tendon, and functions as a fulcrum to maximize the efficiency of the extensor mechanism. The inferior pole of the patella attaches to the patella tendon. The patellar retinaculum is formed by contributions from the fascia lata, vastus medialis, and vastus lateralis. The patella receives centripetal blood supply from the geniculate arteries, with the superior vessels lying anterior to the quadriceps tendon and the inferior vessels passing posterior to the patellar tendon. The most important blood supply to the patella penetrates the inferior pole along the fat pad below the patella.

Fractures of the upper or lower jaw.

A broken hip is a break in the thigh bone (called the "femur") near the hip joint. In older adults, a broken hip can occur from falling or from daily use if the femur is weak. The femur is one of the strongest bones in your body, but it may weaken with age. Even a minor injury may cause the bone to break.

People who have a bone-weakening condition called osteoporosis are more likely to break a hip.

A broken hip is a serious injury that is very painful and can keep you from walking. People with broken hips may be at risk for other problems, such as pneumonia, blood clots, and muscle weakness. Some problems can be life threatening. For that reason, if possible, broken hips are treated with an operation to repair the hip, physical therapy to help you gain strength after the operation, and medicine to help ease the pain.

Fracture of a bone near an articulation with concomitant dislocation of that joint.

Skull Fracture

Fractures of the skull which may result from penetrating or nonpenetrating head injuries or rarely BONE DISEASES (see also FRACTURES, SPONTANEOUS). Skull fractures may be classified by location (e.g., SKULL FRACTURE, BASILAR), radiographic appearance (e.g., linear), or based upon cranial integrity (e.g., SKULL FRACTURE, DEPRESSED).

Skull Fracture, Basilar

Fractures which extend through the base of the SKULL, usually involving the PETROUS BONE. Battle's sign (characterized by skin discoloration due to extravasation of blood into the subcutaneous tissue behind the ear and over the mastoid process), CRANIAL NEUROPATHIES, TRAUMATIC; CAROTID-CAVERNOUS SINUS FISTULA; and CEREBROSPINAL FLUID OTORRHEA are relatively frequent sequelae of this condition.

Skull Fracture, Depressed

A skull fracture characterized by inward depression of a fragment or section of cranial bone, often compressing the underlying dura mater and brain. Depressed cranial fractures which feature open skin wounds that communicate with skull fragments are referred to as compound depressed skull fractures.