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Fracture

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Medical Author:

Benjamin Wedro, MD, FACEP, FAAEM

Benjamin Wedro, MD, FACEP, FAAEM

Dr. Ben Wedro practices emergency medicine at Gundersen Clinic, a regional trauma center in La Crosse, Wisconsin. His background includes undergraduate and medical studies at the University of Alberta, a Family Practice internship at Queen's University in Kingston, Ontario and residency training in Emergency Medicine at the University of Oklahoma Health Sciences Center.

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Medical Editor:

William C. Shiel Jr., MD, FACP, FACR

William C. Shiel Jr., MD, FACP, FACR

Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Fracture facts

• Bone fracture, broken bone, bone crack all mean he same thing. The bone has been damaged such that. None of these terms indicate the severity of the bone damage.
• Bones are the body's storage place for calcium. Under hormone control, calcium content of bone is constantly increasing or decreasing.
• Bones break when they cannot withstand a force or trauma applied to them. Sometimes the bones are so weak that force may be just gravity, like compression fractures of the back in the elderly.
• Fracture descriptions help explain how the breakage appears. For examples, whether or not the fragments are aligned (displaced fracture) and whether or not there is skin overlying the injury is damaged (compound fracture).
• Fractures may be complicated by damage to nearby blood vessels, nerves and muscles and joints.
• Children's fractures may be more difficult to diagnose because their bones lack enough calcium to be seen on X-ray and because growth plates in the bones may disguise or hide the fracture.
• Diagnosis of a fracture includes a history and physical examination. X-rays are often taken. Occasionally, CT or MRI is used to find an occult or hidden fracture or provide more information regarding the damage to the bone and adjacent tissues.
• Fractures of the skull, spine and ribs have their own unique diagnosis and treatment issues.

Introduction to fracture

Bones form the skeleton of the body and allow the body to be supported against gravity and to move and function in the world. Bones also protect some body parts, and bone marrow is the production center for blood products.

Bone is not a stagnant organ. It is the body's reservoir of calcium and is always undergoing change under the influence of hormones. Parathyroid hormone increases blood calcium levels by leeching calcium from bone, while calcitonin has the opposite effect, allowing bone to accept calcium from the blood.

What causes a fracture?

When outside forces are applied to bone it has the potential to fail. Fractures occur when bone cannot withstand those outside forces. Fracture, break, or crack all mean the same thing. One term is not better or worse than another. The integrity of the bone has been damaged and the bone structure fails and a fracture occurs.

Broken bones hurt for a variety of reasons including:

• The nerve endings that surround bones contain pain fiber. These fibers may become irritated when the bone is broken or bruised.
• Broken bones bleed, and the blood and associated swelling (edema) causes pain.
• Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain.

Often a fracture is easy to detect because there is obvious deformity. However, at times it is not easily diagnosed. It is important for the physician to take a history of the injury to decide what potential problems might exist. Moreover, fractures don't always occur in isolation, and there may be associated injuries that need to be addressed.

Fractures can occur because of direct blows, twisting injuries, or falls. The type of forces or trauma applied to the bone may determine what type of injury that occurs. Some fractures occur without any obvious trauma due to osteoporosis, the loss of calcium in bone (for example a compression fracture of the vertebrae of the back). 

Descriptions of fractures can be confusing. They are based on:

• Where in the bone the break has occurred
• How the bone fragments are aligned
• Whether any complications exist
• Whether the skin is intact

The first step in describing a fracture is to decide if it is open or closed. If the skin over the break is disrupted, then an open fracture exists. The skin can be cut, torn, or abraded (scraped), but if the skin's integrity is damaged, the potential for an infection to get into the bone exists. Since the fracture site in the bone communicates with the outside world, these injuries often need to be cleaned out aggressively and many times require anesthesia in the operating room to do the job effectively. Compound fracture was the previous term used to describe an open fracture.

Next, there needs to be a description of the fracture line. Does the fracture line go across the bone (transverse), at an angle (oblique) or does it spiral? Is the fracture in two pieces or is it comminuted, in multiple pieces?

A greenstick fracture describes the situation when the bone partially breaks. This often occurs in infants and children where the bone hasn't completely calcified and has the potential to bend instead of breaking completely through. It is similar to trying to break off a young branch or shoot from a tree (a green stick). Other fracture terms include torus or buckle fracture, again when only part of a bone breaks, but this may occur in adults as well.

Finally, the fracture's alignment is described as to whether the fracture fragments are displaced or in their normal anatomic position. If the bones fragments aren't in the right place, they need to be reduced or placed back into their normal alignment.