Background

Fractures are breaks or disruptions in the continuity of a bone. They can occur for various reasons, including trauma, overuse, and underlying medical conditions.   

• Closed Fracture: This is a fracture where the bone breaks but does not penetrate the skin. It is considered a less severe type of fracture. 
• Open Fracture: In a compound fracture, the broken bone protrudes through the skin. This is a more serious and potentially complicated type of fracture, as it carries an increased risk of infection. 
• Greenstick Fracture: This type of fracture is commonly seen in children. The bone bends and breaks on one side but remains intact on the other, like how a green stick would break. 
• Oblique Fracture: An oblique fracture occurs at an angle across the bone. It is typically the result of a twisting force or a combination of bending and torsion. 
• Spiral Fracture: Spiral fractures are characterized by a twisted or spiraled pattern along the bone. They often result from excessive torsion or twisting forces. 
• Avulsion Fracture: An avulsion fracture happens when a small piece of bone is pulled away from the main bone by a tendon or ligament, often seen in sports-related injuries. 
• Compression Fracture: Compression fractures most commonly occur in the spine and result from the vertebrae being crushed, often due to conditions like osteoporosis or traumatic injury. 
• Comminuted Fracture: In a comminuted fracture, the bone shatters into multiple pieces. This type of fracture is often the result of high-impact trauma. 
• Transverse Fracture: In a transverse fracture, the break occurs horizontally across the bone shaft. It is often caused by a direct blow or impact. 
• Stress Fracture: Stress fractures are hairline cracks in the bone, typically caused by overuse or repetitive stress on the bone. Athletes and individuals engaged in high-impact activities are at greater risk. 
• Pathological Fracture: This type of fracture occurs in bone weakened by an underlying medical condition, such as osteoporosis or bone tumors. 

Epidemiology

• The incidence of fractures varies by age, gender, and geographical location. Fractures are more common in certain populations, such as the elderly and those with specific risk factors like osteoporosis. Some common fractures include hip fractures, wrist fractures, and fractures of the long bones (e.g., femur, tibia). 
• Women tend to experience fractures more often than men, primarily due to a higher prevalence of osteoporosis, a condition that weakens bones. Men are more likely to experience fractures related to trauma and accidents. 
• Fractures can be categorized into trauma fractures (resulting from accidents, falls, sports injuries, etc.) and non-trauma fractures (associated with underlying medical conditions like osteoporosis). Non-trauma fractures are often more prevalent in older adults. 
• Osteoporosis is a significant risk factor for fractures, especially in postmenopausal women. Hip, spine, and wrist fractures are common consequences of osteoporosis, and the condition significantly increases the risk of fractures. 

Anatomy

Pathophysiology

• A fracture can result from excessive force or stress on a bone, leading to structural failure. The specific mechanism of injury can vary, from traumatic incidents such as falls or accidents to overuse or pathological conditions weakening the bone. 
• When a bone fractures, blood vessels within the bone, as well as surrounding soft tissues, are often damaged. This leads to the immediate formation of a hematoma, a localized collection of blood, at the fracture site. Hematoma serves as a natural response to injury and is rich in immune cells, such as neutrophils and macrophages. 
• Osteoblasts, which are specialized bone-forming cells, start to produce a callus. This callus is primarily composed of collagen, cartilage, and bone, and it bridges the gap between the fractured bone ends. The callus stabilizes the fracture and serves as a scaffold for new bone formation. 
• As the callus matures, bone remodeling begins. Osteoclasts, specialized bone-resorbing cells, remove excess bone at the fracture site, while osteoblasts continue to lay down new bone. This process continues until the bone is restored to its pre-fracture strength and shape. 
• The alignment and stabilization of the fractured bone are essential for proper healing. This is achieved through techniques such as casting, splinting, or surgical fixation. 
• Inflammatory cells migrate to the site of the fracture to remove damaged tissue and foreign debris, including bone fragments. This inflammatory response is essential for the initiation of the healing process. 
• Granulation tissue forms at the fracture site, which is rich in fibroblasts and capillaries. This tissue provides the framework for subsequent tissue repair.  

Etiology

• Trauma is one of the most common causes of fractures. This can result from accidents, falls, sports injuries, and physical altercations. High-impact trauma, such as automobile accidents or severe falls, can lead to multiple and complex fractures. 
• As people age, their bone density naturally decreases, making them more susceptible to fractures. This is a significant risk factor for fractures, especially in postmenopausal women. 
• Genetic predisposition can influence bone health and fracture risk. Individuals with a family history of osteoporosis or a tendency to have weaker bones may be at a higher risk of fractures. 
• Inadequate intake of calcium and vitamin D can weaken bones, increasing the likelihood of fractures. Conditions like rickets and osteomalacia can result from severe nutritional deficiencies. 
• Osteoporosis is a medical condition characterized by the weakening of bones, making them more prone to fracture, even with minor stress or falls. Common fractures associated with osteoporosis include hip fractures, vertebral fractures, and wrist fractures. 
• Certain activities or sports that involve repetitive motions can lead to stress fractures. These are small, hairline fractures that develop gradually from repeated stress on the bone. 
• Participation in contact sports, high-impact activities, or extreme sports can increase the risk of fractures, particularly in young and active individuals. 

Genetics

Prognostic Factors

• The type of fracture and its location in the body (e.g., hip, wrist, spine) significantly influence the prognosis. Some fractures are more challenging to treat or have a higher risk of complications. 
• The degree of displacement, angulation, or fragmentation of the fractured bone can affect the prognosis. Severely displaced or unstable fractures may require surgical intervention and have a different prognosis than stable, minimally displaced fractures. 
• Age is a significant prognostic factor. Fractures in older adults may take longer to heal and can be associated with more complications, particularly in the presence of conditions like osteoporosis. 
• Patients with low bone density or poor bone quality, as seen in conditions like osteoporosis, are at greater risk of complications and slower healing. 
• Adequate nutrition, particularly sufficient intake of calcium and vitamin D, is essential for bone health and fracture healing. Malnourished individuals may experience delayed healing. 
• Prompt and appropriate treatment, such as setting and immobilizing the fracture, is crucial for a favorable prognosis. Delays in treatment can lead to complications and suboptimal outcomes. 

Clinical History

• Age Group:  
• Fractures can occur in infants and children due to accidents, falls, or sports injuries. Children are more likely to experience fractures of the upper extremities, such as wrist and forearm fractures, as well as growth plate fractures.  
• This age group is also prone to fractures due to sports injuries, accidents, and recreational activities. Growth plate fractures are more common in adolescents.  
• Fractures can occur in adults of all ages. Traumatic fractures due to accidents and falls are common in this age group. Osteoporotic fractures, particularly in postmenopausal women, are also more prevalent in this age group. 
• Fractures become more common in older adults due to age-related factors such as decreased bone density, muscle strength, and balance. Hip fractures are a significant concern in this age group, often resulting from falls. Vertebral fractures and wrist fractures are also more prevalent in older adults. 

Physical Examination

• History and of Injury: Begin by obtaining a thorough history of the injury. Ask the patient about the circumstances leading to the injury, the location of pain, and any associated symptoms. Understanding the mechanism of injury can provide important clues. 
• Visual Inspection: Examine the affected area visually. Look for any visible deformity, swelling, bruising, or open wounds (in the case of compound fractures). Deformities can include angulation, shortening, or rotation of the affected limb or bone. 
• Palpation: Gently palpate the area surrounding the suspected fracture. Palpation helps identify the point of maximal tenderness and may reveal grinding sensation at the fracture site. 
• Assessment of Neurovascular Status: Evaluate the neurovascular status of the limb or area around the fracture. Check for skin color, temperature, capillary refill time, and the presence of peripheral pulses.  
• Range of Motion: Assess the range of motion at the joint above and below the fracture site.  
• Functional Testing: Depending on the location of the fracture, assess the patient’s ability to bear weight, grasp objects, or perform specific movements.  
• Radiological Evaluation: While physical examination is essential for the initial assessment of a fracture, diagnostic imaging (e.g., X-rays, CT scans, or MRIs) is typically required to confirm the diagnosis, determine the fracture’s exact characteristics, and guide treatment decisions. 

Age group

Associated comorbidity

Associated activity

• Osteoporosis: Osteoporosis is a significant comorbidity, especially in older adults and postmenopausal women. It results in reduced bone density and increased bone fragility, making individuals more susceptible to fractures, particularly of the hip, spine, and wrist. 
• Diabetes: Diabetes can affect the healing process of fractures due to compromised blood flow, neuropathy, and impaired immune function. It may increase the risk of complications, such as infection or delayed healing. 
• Obesity: Obesity can increase the risk of fractures due to the extra weight and stress on bones. However, it can also offer some protection in certain types of fractures, such as hip fractures, by cushioning the fall. 
• Malnutrition: Poor nutrition can delay fracture healing by impairing the body’s ability to produce new bone and repair tissues. Adequate protein, vitamins, and minerals are essential for fracture healing. 
• Rheumatoid Arthritis: Individuals with rheumatoid arthritis have an increased risk of fractures, often related to both the disease process itself and the use of medications like corticosteroids. 
• Neurological Conditions: Conditions like Parkinson’s disease, multiple sclerosis, and stroke can affect balance and coordination, increasing the risk of falls and fractures. 

Acuity of presentation

• Acute and traumatic type of fractures occur suddenly and are often the result of a traumatic event, such as a fall, car accident, or sports injury. Acute fractures are usually associated with severe pain, swelling, deformity, and loss of function.  
• They require immediate medical attention, and diagnostic imaging (e.g., X-rays) is typically performed promptly to assess the severity and location of the fracture. Treatment may involve reduction (realigning the bone fragments) and immobilization with casts, splints, or surgical fixation. 
• Subacute fractures are those that occur more gradually or are not immediately recognized as fractures. Patients may have delayed or atypical symptoms, and the injury may not be diagnosed until days or weeks after the initial trauma.  
• These fractures may still require prompt treatment, but the urgency is less than with acute fractures. Early diagnosis and appropriate management are essential to avoid complications.  
• Chronic fractures are those that have gone undiagnosed or untreated for an extended period, often several weeks or months. These fractures may not present with acute symptoms but can cause chronic pain, deformity, and functional limitations.  
• Stress fractures are typically due to overuse or repetitive stress and may present with milder, persistent pain. The acuity of presentation can vary, with some stress fractures being diagnosed early, while others may go undetected until they worsen.  

Differential Diagnoses

• Hematomas: Bruises and hematomas can cause pain, swelling, and discoloration that may resemble fracture symptoms. 
• Sprains and Strains: Ligament and muscle injuries can cause pain, swelling, and limited range of motion, like some fractures.  
• Infections: Infections, such as cellulitis or osteomyelitis, can cause localized pain, swelling, and redness, which may mimic the signs of a fracture.  
• Nerve Injuries: Damage to nerves, such as a pinched nerve, can cause pain, numbness, and tingling like some fractures. Clinical assessment and nerve conduction studies may help distinguish nerve injuries from fractures. 
• Dislocations: Joint dislocations can result in deformities and restricted movement like fractures. X-rays can help confirm whether a dislocation is present. 
• Stress Injuries: Stress fractures and overuse injuries can be mistaken for acute fractures. These injuries typically develop gradually and are often associated with repetitive stress or excessive physical activity. 
• Arthritis: Inflammatory joint conditions like rheumatoid arthritis or osteoarthritis can lead to joint pain, stiffness, and swelling, which may resemble fracture symptoms.  
• Bursitis: Inflammation of the bursae, small fluid-filled sacs near joints, can lead to localized pain and swelling, often in joints. Bursitis can mimic some fracture symptoms. 
• Vascular Injuries: Vascular injuries, such as vascular compression syndromes or thrombosis, can cause pain, swelling, and changes in skin color. 

Laboratory Studies

Imaging Studies

Procedures

Histologic Findings

Staging

Treatment Paradigm

• Initial Assessment and Stabilization: Begin with a thorough clinical assessment, including a history of the injury, physical examination, and evaluation of neurovascular status. Immobilize the fracture using splints, slings, or casts to prevent further injury and alleviate pain. 
• Pain Management: Administer appropriate pain management, which may include analgesics or non-steroidal anti-inflammatory drugs (NSAIDs). 
• Diagnostic Imaging: X-rays: Perform X-rays to confirm the presence of a fracture, determine the fracture’s characteristics, and assess its alignment. 
• Immobilization and Casting: After reduction, immobilize the fracture with a cast, splint, or brace to maintain alignment and provide support for healing. The choice of immobilization method depends on the type and location of the fracture.
• Non-Surgical Management: For stable fractures that do not require surgery, non-surgical management with immobilization and close follow-up may be sufficient. This is common for simple, non-displaced fractures. 
• Rehabilitation and Physical Therapy: Following immobilization or surgical intervention, patients typically require rehabilitation and physical therapy. These programs help restore strength, range of motion, and functional mobility. 
• Monitoring and Follow-Up: Regular follow-up appointments are essential to assess the progress of healing and address any complications that may arise. 
• Nutrition and Bone Health: Ensure patients have a balanced diet with sufficient calcium and vitamin D to support bone healing and health. 
• Pain Management: Continue to manage pain and address any associated symptoms, such as swelling, as the patient heals. 

by Stage

by Modality

Chemotherapy

Radiation Therapy

Surgical Interventions

Hormone Therapy

Immunotherapy

Hyperthermia

Photodynamic Therapy

Stem Cell Transplant

Targeted Therapy

Palliative Care

use-of-non-pharmacological-approach-for-fractures

• Home Assessment: Consider conducting a home assessment to identify potential hazards and make necessary modifications. This can be done by an occupational therapist. 
• Fall Prevention: Fracture patients, particularly the elderly, are at a higher risk of falls. Implement fall prevention strategies, which may include removing loose rugs, securing cords and cables, and ensuring good lighting throughout the home. 
• Mobility Aids: Provide mobility aids such as crutches, a walker, or a wheelchair, as prescribed by a physician. Clear pathways in the home to accommodate these aids. 
• Furniture modification: Rearrange furniture to create clear and wide pathways to navigate with mobility aids. Consider removing obstacles, such as low tables, that may pose a tripping hazard. 
• Assistive Devices: Use assistive devices, to help with tasks that require bending or stretching. Adapt utensils and tools for ease of use, such as using built-up handles. 

• Medication Management: Ensure the patient has easy access to prescribed medications and is compliant with the medication regimen for pain management and other treatments. 
• Psychological Support: Creating a supportive and encouraging environment is essential. Family members and caregivers should provide emotional support and help alleviate any anxiety or depression that may accompany the healing process. 
• Meal Preparation: Help ensure the patient has access to nutritious meals, whether through home-cooked or meal delivery services. 
• House Modifications: Install grab bars in the shower or bath to provide support while standing or sitting. Use non-slip bathmats to prevent slipping in wet areas. 

Adjust the height of the bed to facilitate getting in and out and ensure there are handrails or supports near the bed. 

Use of NSAID’s

• Ibuprofen: It is a non-steroidal anti-inflammatory drug (NSAID) commonly used to manage pain and inflammation, and it may have a role in the treatment of fractures in certain situations.  

Ibuprofen is effective in reducing pain associated with fractures. It can help alleviate pain caused by inflammation at the fracture site, as well as pain from surrounding soft tissues.  

By reducing pain, it can improve the patient’s overall comfort and quality of life during the healing process. 

• Naproxen: It is effective at reducing pain associated with fractures. It can help alleviate pain caused by inflammation at the fracture site and surrounding soft tissues.  

Use of Antibiotics

Antibiotics are used to prevent or treat bacterial infections that can occur because of the fracture.  

• Cefazolin: Cefazolin is a first-generation cephalosporin antibiotic and is often used as prophylactic antibiotic therapy before surgery for fracture management. It provides coverage against a broad spectrum of bacteria, including those commonly encountered in orthopaedic surgeries. 
• Clindamycin: Clindamycin is used as an alternative to cefazolin in cases of allergies or sensitivities to cephalosporin antibiotics. It is effective against many bacteria commonly found in orthopaedic infections. 

Use of bone density enhancements agents

• Bisphosphonates: It is a class of medications used to treat and prevent conditions like osteoporosis, which can lead to fractures, especially in older adults. They help to strengthen bone density and reduce the risk of fractures by inhibiting bone resorption (the breakdown of bone tissue). 

Bisphosphonates are typically prescribed to individuals with osteoporosis or those at high risk of fractures due to conditions like glucocorticoid-induced osteoporosis.  

Use of Anticoagulants

After a fracture, especially in cases of lower extremity fractures (e.g., hip or femur fractures), patients may have reduced mobility due to immobilization or surgery.  

Reduced mobility can increase the risk of blood clots forming in the deep veins of the legs (DVT) that can potentially dislodge and travel to the lungs, causing a pulmonary embolism (PE). 

• Heparin: It is available in intravenous and subcutaneous forms and acts rapidly to prevent blood clot formation. 
• Low Molecular Weight Heparins (LMWHs): The examples include enoxaparin and dalteparin. LMWHs are often used for DVT prophylaxis and are administered subcutaneously. 
• Warfarin: Warfarin is an oral anticoagulant and is typically used for longer-term anticoagulation. It requires regular monitoring of the International Normalized Ratio to ensure the appropriate level of anticoagulation. 

Use of Nutritional Supplements

• Calcium and vitamin D: These are essential nutrients for bone health. Calcium is a primary building block of bone, while vitamin D is crucial for calcium absorption.  

Calcium and vitamin D supplements are often recommended for individuals with dietary deficiencies, impaired absorption of these nutrients, or who are at risk of osteoporosis. They can help prevent bone loss and reduce the risk of fractures, particularly in older adults. 

use-of-intervention-with-a-procedure-in-treating-fractures

• Closed Reduction: In a closed reduction, a healthcare provider manually manipulates the bone fragments to realign them without making an incision. This is typically done under sedation or anesthesia. 

Following successful reduction, the fractured bone may be immobilized using a cast, splint, or brace to maintain alignment. 

• Open Reduction and Internal Fixation (ORIF): ORIF is a surgical procedure where an incision is made to access the fracture site. The bone fragments are realigned, and various fixation devices, such as screws, plates, or rods, are used to stabilize the fracture. 

ORIF is used for complex fractures, fractures with significant displacement, or fractures near joints where precise alignment is necessary.  

• External Fixation: External fixation involves the use of pins or wires inserted into the bone fragments, which are then connected to an external frame. This provides stability and allows for adjustments. 

External fixation is often used for open fractures with soft tissue damage, as it can accommodate swelling and wound care.  

• Casting and Splinting: Casting and splinting involve the application of a cast or splint to immobilize the fractured bone, prevent further injury, and promote healing. 

Casting and splinting are commonly used for stable fractures with minimal displacement, such as certain wrist and ankle fractures. 

• Traction: Traction involves the application of a pulling force to the fractured bone, often using weights and pulleys, to realign and stabilize the fracture. 

Traction is typically used in cases of long bone fractures, such as femoral fractures. 

• Functional Bracing: Functional bracing involves the use of braces designed to allow limited motion at the fracture site while providing stability. 

Functional bracing is used for certain fractures that can benefit from early mobilization, such as stable midshaft tibia fractures. 

• Nailing and Rodding: It involve the insertion of a metal rod into the intramedullary canal of long bones (e.g., femur or tibia) to stabilize and align the fracture. 

This procedure is common for certain diaphyseal fractures, where it allows for excellent stability. 

use-of-phases-in-managing-fractures

• Assessment and Diagnosis Phase: In this initial phase, the healthcare provider assesses the fracture through a combination of a clinical evaluation, patient history, and diagnostic imaging (X-rays, CT scans, MRI). 
• Stabilization and Pain Management Phase: The priority is to stabilize the fracture to prevent further injury and reduce pain. Immobilization methods, such as splints, casts, or external fixation, are employed to maintain the alignment of the fractured bone. 
• Rehabilitation and Physical Therapy: Rehabilitation and physical therapy are essential components of the management process. These programs focus on restoring the patient’s strength, range of motion, and functional mobility. 
• Monitoring and Follow-Up Phase: Regular follow-up appointments are scheduled to assess the progress of healing and address any complications. 
• Symptom Control Phase: Pain management and control of associated symptoms, such as swelling and inflammation, continue throughout the management process. 
• Functional Recovery Phase: As the fracture heals and immobilization is removed, the patient works on regaining functional independence and returning to their normal activities. 

Medication

Future Trends

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References

• Current and Future Concepts for the Treatment of Impaired Fracture Healing – PMC (nih.gov) 
• Fracture healing: mechanisms and interventions – PMC (nih.gov) 
• Fractures (Broken Bones) – OrthoInfo – AAOS