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Fracture of Bones; Types, Mechanism, Symptoms

Fracture of Bones is a medical condition in which there is a partial or complete break in the continuity of the bone. In more severe cases, the bone may be broken into several pieces.^[rx] A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.^[rx]

Types of Fracture of Bones

Mechanism

Traumatic fracture – This is a fracture due to sustained trauma. e.g., fractures caused by a fall, road traffic accident, fight, etc.
Pathologic fracture – A fracture through a bone that has been made weak by some underlying disease is called pathological fracture. e.g., a fracture through a bone weakened by metastasis. Osteoporosis is the most common cause of pathological fracture.
Periprosthetic fracture – This is a fracture at the point of mechanical weakness at the end of an implant

Soft-tissue involvement

Closed fractures are those in which the overlying skin is intact
Open/compound fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.
- Clean fracture
- Contaminated fracture

Displacement

Non-displaced
Displaced
- Translated, or ad latus, with sideways displacement.^[11]
- Angulated
- Rotated
- Shortened

Fracture Pattern

Linear fracture – A fracture that is parallel to the bone’s long axis
Transverse fracture – A fracture that is at a right angle to the bone’s long axis
Oblique fracture – A fracture that is diagonal to a bone’s long axis (more than 30°)
Spiral fracture – A fracture where at least one part of the bone has been twisted
Compression fracture/wedge fracture – usually occurs in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma)
Impacted fracture – A fracture caused when bone fragments are driven into each other
Avulsion fracture – A fracture where a fragment of bone is separated from the main mass

Fragments

Incomplete fracture – Is a fracture in which the bone fragments are still partially joined, in such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone.
Complete fracture – Is a fracture in which bone fragments separate completely.
Comminuted fracture – Is a fracture in which the bone has broken into several pieces.

Fracture types

Avulsion fracture
Articular surface injuries
- Bone contusion
- Chondral fracture
- Subchondral fracture
- Subchondral insufficiency fracture

Osteochondral fracture

Complete fracture
Transverse fracture
Oblique fracture
Spiral fracture
Longitudinal fracture
Comminuted fracture
segmental fracture
Incomplete fracture
- Bowing fracture
- Buckle fracture (torus)
- Greenstick fracture
Compound fracture
- Gustilo Anderson classification (compound fracture)
Pathological fracture
Stress fracture
- insufficiency fracture
- fatigue fracture
  - grey cortex sign

Fracture displacement

Fracture translation > off-ended fracture
Fracture angulation
Fracture rotation
Fracture length
- distraction
- impaction
- shortening

Skull Fractures

The base of skull fractures
Occipital condyle fracture
Temporal bone fractures
- Longitudinal fractures
- Transverse fractures
- Mixed fractures
- Transsphenoidal basilar skull fracture
Skull vault fractures
- Depressed skull fracture
- Ping pong skull fracture

Facial fractures

Fractures involving a single facial buttress
Alveolar process fractures
Frontal sinus fracture
Isolated zygomatic arch fractures
Mandibular fracture
Nasal bone fracture
Orbital blow-out fracture
Paranasal sinus fractures

Complex fractures

Complex midfacial fracture
Le Fort fractures
Naso-orbitoethmoid (NOE) complex fracture
Zygomaticomaxillary complex fracture

Cervical spine fracture classification systems

AO classification of upper cervical injuries
AO classification of subaxial injuries
Anderson and D’Alonzo classification (odontoid fracture)
Levine and Edwards classification (hangman fracture)
Roy-Camille classification (odontoid process fracture )
Allen and Ferguson classification (subaxial spine injuries)
subaxial cervical spine injury classification (SLIC)

Thoracolumbar spinal fracture classification systems

AO classification of thoracolumbar injuries
Magerl classification
McAfee classification
Thoracolumbar injury classification and severity score (TLICS)
Limbus fractures

- Three column concept of spinal fractures (Denis classification)
- Classification of sacral fractures
- AO classification of sacral injuries

Cervical spine fractures

clay-shoveler’s fracture
dens fracture
hangman fracture
Jefferson fracture
extension teardrop fracture
flexion teardrop fracture
cervical spine floating pillar

Thoracic spine fractures

Chance fracture
Transverse process fracture
Spondylolysis
- lumbar spine fractures
- sacral fractures

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Spinal fracture types

Burst fracture
Chance fracture
Clay-shoveler fracture
Chalk stick fracture
Dens fracture
Extension teardrop fracture
Flexion teardrop fracture
Hangman fracture
Jefferson fracture
Vertebra plana
Wedge fracture

Rib fractures

Flail chest
Stove-in chest
Sternal fractures

Upper limb fractures classification

Rockwood classification (acromioclavicular joint injury)
Neer classification (proximal humeral fracture)
AO classification (proximal humeral fracture)
Milch classification (lateral humeral condyle fracture)
Weiss classification (lateral humeral condyle fracture)
Bado classification of Monteggia fracture-dislocations (radius-ulna)
Mason classification (radial head fractures
Frykman classification (distal radial fracture)

Mayo classification (scaphoid fracture)

Hintermann classification (gamekeeper’s thumb)
Eaton classification (volar plate avulsion injury)
Keifhaber-Stern classification (volar plate avulsion injury)

Upper limb fractures by region

Shoulder

Clavicular fracture
Scapular fracture
Acromion fracture
Coracoid process fracture
Glenoid fracture
- Bankart lesion
- reverse Bankart lesion

Humeral head fracture

Hill-Sachs lesion
reverse Hill-Sachs lesion
proximal humeral fracture
humeral neck fracture

Arm

Humeral shaft fracture

Elbow

Humeral condyle fracture
Lateral humeral condyle fracture
Medial humeral condyle fracture
Epicondyle fracture
Medial epicondyle fracture
Lateral epicondyle fracture
Olecranon fracture
Supracondylar fracture (extension)
Supracondylar fracture (flexion)
Radial head fracture
Radial neck fracture

Forearm

Forearm fracture-dislocation
Essex-Lopresti fracture-dislocation
Galeazzi fracture-dislocation
Monteggia fracture-dislocation
Forearm fracture
nightstick fracture

Wrist > distal radial fracture

Chauffeur fracture
Colles fracture
Smith fracture
Barton fracture
reverse Barton fracture

Distal ulnar fracture

Ulnar styloid fracture
Carpal bones
Humpback deformities
Scaphoid fracture
Scaphoid non-union
A scaphoid non-union advanced collapse

Lunate fracture

Perilunate fracture-dislocation
Lunate dislocation
Capitate fracture
Triquetral fracture
Pisiform fracture
Hamate fracture
Hook of hamate fracture
Trapezoid fracture
Trapezium fracture

Hand

Metacarpal fractures > boxer fracture & reverse Bennett fracture-dislocation

Fractures of the thumb

Gamekeeper thumb
Epibasal fracture of the thumb
Rolando fracture
Bennett fracture-dislocation

Phalanx fractures

Proximal phalanx fracture
Middle phalanx fracture
Volar plate avulsion injury
Distal phalanx fracture
- Jersey finger
- mallet finger

Lower limb fractures > classification by region

pelvis
Judet and Letournel classification (acetabular fracture)
Young and Burgess classification of pelvic ring fractures

Hip

Pipkin classification (femoral head fracture)
Garden classification (hip fracture)
American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
Cooke and Newman classification (periprosthetic hip fracture)
Johansson classification (periprosthetic hip fracture)
Vancouver classification (periprosthetic hip fracture)

Femoral

Winquist classification (femoral shaft fracture)

Knee

Schatzker classification (tibial plateau fracture)
Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)

Tibia/fibula

Watson-Jones classification (tibial tuberosity avulsion fracture)

Ankle

Lauge-Hansen classification (ankle injury)
Danis-Weber classification (ankle fracture)

Foot

Berndt and Harty classification (osteochondral lesions of the talus)
Sanders CT classification (calcaneal fracture)
Hawkins classification (talar neck fracture)
Myerson classification (Lisfranc injury)
Nunley-Vertullo classification (Lisfranc injury)

Lower limb fractures by region> pelvic fracture

Malgaigne fracture
Wind-swept pelvis fracture
Pelvic bucket handle fracture
Pelvic insufficiency fracture
Parasymphyseal insufficiency fracture
anterior inferior iliac spine avulsion
Duverney fracture
Open book fracture
Pubic rami fracture
Anterior superior iliac spine (ASIS) avulsion

Sacral fracture

Sacral insufficiency fractures
Honda sign

Hip

Acetabular fracture
Femoral head fracture
Femoral neck fracture
- subcapital fracture
- transcervical fracture
- basicervical fracture

Trochanteric fracture

Pertrochanteric fracture
Intertrochanteric fracture
Subtrochanteric fracture

Thigh

Mid-shaft fracture
Bisphosphonate-related fracture

Knee > avulsion fractures

Segond fracture
Reverse Segond fracture
Anterior cruciate ligament avulsion fracture
Posterior cruciate ligament avulsion fracture
Arcuate complex avulsion fracture (arcuate sign)
Biceps femoris avulsion fracture
Iliotibial band avulsion fracture
Semimembranosus tendon avulsion fracture
Stieda fracture (MCL avulsion fracture)
Patella fracture
Tibial plateau fracture

leg

Tibial tuberosity avulsion fracture
Tibial shaft fracture
Fibular shaft fracture
Maisonneuve fracture

Ankle

Bimalleolar fracture
Trimalleolar fracture
Triplane fracture
Tillaux fracture
Bosworth fracture
Pilon fracture
Wagstaffe-Le Forte fracture

Foot

Tarsal bones
Chopart fracture
Calcaneal fracture
Lover’s fracture
Calcaneal tuberosity avulsion fracture

Talus fracture

Talar body fractures
Talar dome osteochondral fracture
Posterior talar process fracture
Lateral talar process fracture
Talar neck fracture
- aviator fracture
- talar head fracture
- navicular fracture
- medial cuneiform fracture
- intermediate cuneiform fracture
- lateral cuneiform fracture
- cuboid fracture
- nutcracker fracture

Metatarsal Bones

March fracture
Lisfranc fracture-dislocation
5th metatarsal fracture
Stress fracture of the 5th metatarsal
Jones fracture
Pseudo-Jones fracture
Avulsion fracture of the proximal 5th metatarsal
phalanges

Classification parameter

fracture types

- - avulsion fracture
  - articular surface injuries
    - bone contusion
    - chondral fracture
    - subchondral fracture
      - subchondral insufficiency fracture
    - osteochondral fracture
  - complete fracture
    - transverse fracture
    - oblique fracture
    - spiral fracture
    - longitudinal fracture
    - comminuted fracture
    - segmental fracture
  - incomplete fracture
    - bowing fracture
    - buckle fracture (torus)
    - greenstick fracture
  - infraction
  - compound fracture
    - Gustilo Anderson classification (compound fracture)
  - pathological fracture
  - stress fracture
    - insufficiency fracture
    - fatigue fracture
      - grey cortex sign
- fracture displacement
  - fracture translation
    - off-ended fracture
  - fracture angulation
  - fracture rotation
  - fracture length
    - distraction
    - impaction
    - shortening
skull fractures[–]
- base of skull fractures
  - occipital condyle fracture
  - temporal bone fractures
    - longitudinal fractures
    - transverse fractures
    - mixed fractures
  - transsphenoidal basilar skull fracture
- skull vault fractures
  - depressed skull fracture
  - ping pong skull fracture
facial fractures[–]
- fractures involving a single facial buttress
  - alveolar process fractures
  - frontal sinus fracture
  - isolated zygomatic arch fractures
  - mandibular fracture
  - nasal bone fracture
  - orbital blow-out fracture
  - paranasal sinus fractures
- complex fractures
  - complex midfacial fracture
  - Le Fort fractures
  - naso-orbitoethmoid (NOE) complex fracture
  - zygomaticomaxillary complex fracture
spinal fractures[–]
- classification (AO Spine classification systems)
  - cervical spine fracture classification systems
    - AO classification of upper cervical injuries
    - AO classification of subaxial injuries
    - Anderson and D’Alonzo classification (odontoid fracture)
    - Levine and Edwards classification (hangman fracture)
    - Roy-Camille classification (odontoid process fracture )
    - Allen and Ferguson classification (subaxial spine injuries)
    - subaxial cervical spine injury classification (SLIC)
  - thoracolumbar spinal fracture classification systems
    - AO classification of thoracolumbar injuries
    - Magerl classification
    - McAfee classification
    - thoracolumbar injury classification and severity score (TLICS)
    - limbus fractures
  - three column concept of spinal fractures (Denis classification)
  - classification of sacral fractures
    - AO classification of sacral injuries
- spinal fractures by region
  - cervical spine fractures
    - clay-shoveler’s fracture
    - dens fracture
    - hangman fracture
    - Jefferson fracture
    - extension teardrop fracture
    - flexion teardrop fracture
    - cervical spine floating pillar
  - thoracic spine fractures
    - Chance fracture
    - transverse process fracture
    - spondylolysis
  - lumbar spine fractures
  - sacral fractures
- spinal fracture types
  - burst fracture
  - Chance fracture
  - clay-shoveler fracture
  - chalk stick fracture
  - dens fracture
  - extension teardrop fracture
  - flexion teardrop fracture
  - hangman fracture
  - Jefferson fracture
  - vertebra plana
  - wedge fracture
rib fractures[–]
- flail chest
- stove-in chest
sternal fractures
upper limb fractures
- classification
  - Rockwood classification (acromioclavicular joint injury)
  - Neer classification (proximal humeral fracture)
  - AO classification (proximal humeral fracture)
  - Milch classification (lateral humeral condyle fracture)
  - Weiss classification (lateral humeral condyle fracture)
  - Bado classification of Monteggia fracture-dislocations (radius-ulna)
  - Mason classification (radial head fracture)
  - Frykman classification (distal radial fracture)
  - Mayo classification (scaphoid fracture)
  - Hintermann classification (gamekeeper’s thumb)
  - Eaton classification (volar plate avulsion injury)
  - Keifhaber-Stern classification (volar plate avulsion injury)
- upper limb fractures by region[–]
  - shoulder
    - clavicular fracture
    - scapular fracture
      - acromion fracture
      - coracoid process fracture
      - glenoid fracture
        
        Bankart lesion
        
        reverse Bankart lesion
    - humeral head fracture
      - Hill-Sachs lesion
      - reverse Hill-Sachs lesion
    - proximal humeral fracture
    - humeral neck fracture
  - arm
    - humeral shaft fracture
  - elbow
    - humeral condyle fracture
      - lateral humeral condyle fracture
      - medial humeral condyle fracture
    - epicondyle fracture
      - medial epicondyle fracture
      - lateral epicondyle fracture
    - olecranon fracture
    - supracondylar fracture (extension)
    - supracondylar fracture (flexion)
    - radial head fracture
    - radial neck fracture
  - forearm
    - forearm fracture-dislocation
      - Essex-Lopresti fracture-dislocation
      - Galeazzi fracture-dislocation
      - Monteggia fracture-dislocation
    - forearm fracture
      - nightstick fracture
  - wrist
    - distal radial fracture
      - Chauffeur fracture
      - Colles fracture
      - Smith fracture
      - Barton fracture
      - reverse Barton fracture
    - distal ulnar fracture
      - ulnar styloid fracture
  - carpal bones
    - scaphoid fracture
      - scaphoid non-union
        
        scaphoid non-union advanced collapse
      - humpback deformity
    - lunate fracture
      - perilunate fracture-dislocation
      - lunate dislocation
    - capitate fracture
    - triquetral fracture
    - pisiform fracture
    - hamate fracture
      - hook of hamate fracture
    - trapezoid fracture
    - trapezium fracture
  - hand
    - metacarpal fractures
      - boxer fracture
      - reverse Bennett fracture-dislocation
    - fractures of the thumb
      - gamekeeper thumb
      - epibasal fracture of the thumb
      - Rolando fracture
      - Bennett fracture-dislocation
    - phalanx fractures
      - proximal phalanx fracture
      - middle phalanx fracture
        
        volar plate avulsion injury
      - distal phalanx fracture
        
        Jersey finger
        
        mallet finger
lower limb fractures
- classification by region
  - pelvis
    - Judet and Letournel classification (acetabular fracture)
    - Young and Burgess classification of pelvic ring fractures
  - hip
    - Pipkin classification (femoral head fracture)
    - Garden classification (hip fracture)
    - American Academy of Orthopedic Surgeons classification (periprosthetic hip fracture)
    - Cooke and Newman classification (periprosthetic hip fracture)
    - Johansson classification (periprosthetic hip fracture)
    - Vancouver classification (periprosthetic hip fracture)
  - femoral
    - Winquist classification (femoral shaft fracture)
  - knee
    - Schatzker classification (tibial plateau fracture)
    - Meyers and McKeevers classification (anterior cruciate ligament avulsion fracture)
  - tibia/fibula
    - Watson-Jones classification (tibial tuberosity avulsion fracture)
  - ankle
    - Lauge-Hansen classification (ankle injury)
    - Danis-Weber classification (ankle fracture)
  - foot
    - Berndt and Harty classification (osteochondral lesions of the talus)
    - Sanders CT classification (calcaneal fracture)
    - Hawkins classification (talar neck fracture)
    - Myerson classification (Lisfranc injury)
    - Nunley-Vertullo classification (Lisfranc injury)
- lower limb fractures by region
  - pelvic fracture
    - Malgaigne fracture
    - wind-swept pelvis fracture
    - pelvic bucket handle fracture
    - pelvic insufficiency fracture
      - parasymphyseal insufficiency fracture
    - anterior inferior iliac spine avulsion
    - Duverney fracture
    - open book fracture
    - pubic rami fracture
    - anterior superior iliac spine (ASIS) avulsion
  - sacral fracture
    - sacral insufficiency fractures
      - Honda sign
  - hip
    - acetabular fracture
    - femoral head fracture
    - femoral neck fracture
      - subcapital fracture
      - transcervical fracture
      - basicervical fracture
    - trochanteric fracture
      - pertrochanteric fracture
      - intertrochanteric fracture
      - subtrochanteric fracture
  - thigh
    - mid-shaft fracture
    - bisphosphonate-related fracture
  - knee
    - avulsion fractures
      - Segond fracture
      - reverse Segond fracture
      - anterior cruciate ligament avulsion fracture
      - posterior cruciate ligament avulsion fracture
      - arcuate complex avulsion fracture (arcuate sign)
      - biceps femoris avulsion fracture
      - iliotibial band avulsion fracture
      - semimembranosus tendon avulsion fracture
      - Stieda fracture (MCL avulsion fracture)
    - patella fracture
    - tibial plateau fracture
  - leg
    - tibial tuberosity avulsion fracture
    - tibial shaft fracture
    - fibular shaft fracture
    - Maisonneuve fracture
  - ankle
    - bimalleolar fracture
    - trimalleolar fracture
    - triplane fracture
    - Tillaux fracture
    - Bosworth fracture
    - pilon fracture
    - Wagstaffe-Le Forte fracture
  - foot
    - tarsal bones
      - Chopart fracture
      - calcaneal fracture
        
        lover’s fracture
        
        calcaneal tuberosity avulsion fracture
      - talus fracture
        
        talar body fractures
        
        talar dome osteochondral fracture
        
        posterior talar process fracture
        
        lateral talar process fracture
        
        talar neck fracture
        
        aviator fracture
        
        talar head fracture
      - navicular fracture
      - medial cuneiform fracture
      - intermediate cuneiform fracture
      - lateral cuneiform fracture
      - cuboid fracture
        
        nutcracker fracture
    - metatarsal bones
      - general
        
        march fracture
        
        Lisfranc fracture-dislocation
      - 5th metatarsal fracture
        
        stress fracture of the 5th metatarsal
        
        Jones fracture
        
        pseudo-Jones fracture
        
        avulsion fracture of the proximal 5th metatarsal
    - phalanges

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Symptoms of Fracture of Bones

Although bone tissue itself contains no nociceptors, the bone fracture is painful for several reasons:^[rx]

Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple pain receptors.
Edema of nearby soft tissues caused by bleeding of broken periosteal blood vessels evokes pressure pain.
Involuntary muscle spasms trying to hold bone fragments in place.
Hematoma on the fracture site.

Damage to adjacent structures such as nerves, muscles or blood vessels, spinal cord, and nerve roots (for spine fractures), or cranial contents (for skull fractures) may cause other specific signs and symptoms.

Complications

An old fracture with nonunion of the fracture fragments

Some fractures may lead to serious complications including a condition known as compartment syndrome. If not treated, eventually, compartment syndrome may require amputation of the affected limb. Other complications may include non-union, where the fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed manner.

Complications of fractures may be classified into three broad groups, depending upon their time of occurrence. These are as follows –

Immediate complications – occurs at the time of the fracture.
Early complications – occurring in the initial few days after the fracture.
Late complications – occurring a long time after the fracture.

Immediate complications	Early complications	Late complications
Systemic Hypovolaemic shock	Systemic Hypovolaemic shock ARDS – Adult respiratory distress syndrome Fat embolism syndrome Deep vein thrombosis Pulmonary syndrome Aseptic traumatic fever Septicemia (in open fracture ) Crush syndrome	Imperfect union of the fracture Delayed union Nonunion Malunion Cross union
Local Injury to major vessels Injury to muscles and tendons Injury to joints Injury to viscera	Local Infection Compartment syndrome	Others Avascular necrosis Shortening Joint stiffness Sudeck’s dystrophy Osteomyelitis Ischaemic contracture Myositis ossificans Osteoarthritis