Fractures

A fractured bone is a medical term for the break in the continuity of the bone. There are several different types of fractures, most of which are caused by high levels of force. However some are caused by underlying pathology which can cause a weakness to the bone resulting in a pathological fracture (Campagne, 2021;Throckmorton, 2021).

Symptoms and signs:

• pain
• bleeding
• swelling
• deformity
• redness and/or bruising
• loss of use of structures that are supported by the bone in question, such as reduced movement of a wrist 
• sensation changes with associated nerve injury
• cool or cold limb distal to the fracture sustained with associated vascular injury
• bone penetration through the skin
• associated wounds
• other associated trauma

Most fractures are caused by degrees of trauma. However, some fractures are related to underlying medical conditions; these are called pathological fractures. Pathological fractures are caused by a weakening of the bone by either a local or systemic process ongoing in the body (LJ et al, 1997; National Institute for Health and Care Excellence (NICE), 2016a). A further set of fractures can be caused by repetitive stress, strain or overuse of the bone - these are known as stress fractures.  

Common traumatic mechanisms of injury include:

• falls
• road traffic accidents
• sport
• attempted suicide
• industry related injury

Common conditions leading to pathological fractures include:

• osteoporosis - a common bone disease seen in older populations where the bone becomes much weaker and more brittle (LJ et al, 1997; Warriner et al, 2011)
• cancers - bone metastasis from a cancer most commonly from the lung, breast, prostate, kidney and thyroid or a primary bone cancer (Rizzoli

Diagnosis of a fracture begins with a history and examination of the patient, looking for the symptoms and signs previously stated above. When examining, be sure to be aware of the joints above and below the area of concern as there can often be associated injuries. When there is a suspicion that a fracture might be present then the first line of investigation is usually an X-ray of the affected area. When getting an X-ray of a suspected fracture it can be beneficial to consider the rule of twos (Touquet et al, 1995) 

• two views (x-rays at right angles to each other)
• two joints (above and below the injury)
• two sides - for subtle epiphyseal injuries to paediatric cases
• two occasions - if a fracture is not seen the first time and the injury continues to cause issues it could have been a missed fracture
• two x-rays - if the

Immediately following a fracture, pain tends to be the greatest symptom (NICE, 2016a; 2016b). This is due to disruption of mechanosensitive nerve fibres surrounding the bone which send quick fire signals to the brain to express pain. Over some time (minutes to hours) various inflammatory hormones and chemicals are released near the fracture which stimulate sympathetic and sensory pain nerves to fire off, which upon movement give a sharp pain and on rest a dull ache (Mitchell et al, 2018). Therefore, as movement at the fracture site is the main cause of pain the mainstay of management is immobilisation with adequate analgesia. Immobilisation in the first instance can be in the form of a splint such as a plaster of paris, or with braces.  

The next concern is swelling. As the body identifies a traumatic injury, blood vessels become more porous and release a variety of helpful nutrients, blood cells,

Mainstay is anatomical reduction and immobilisation in order to allow for sufficient bone healing (NICE, 2016a; NICE, 2016b). This can be in the form of:

• conservative 
• casting
• buddy strapping
• splints or braces
• surgical
• plates and screws
• intramedullary nails
• k-wires
• external fixation devices
• traction
• replacement 

Before, during and after the healing process the patient will need to be rehabilitated in order to maintain sufficient function. This involves techniques such as early mobilisation and strengthening exercises in order to reduce complications such as stiffness, muscle atrophy and immobility.

References

Anderson MW, Greenspan A. Stress fractures. Radiology. 1996;199(1), pp. 1–12. https://doi.org/10.1148/radiology.199.1.8633129

Campagne, D. Overview of Fractures. 2021. https://www.msdmanuals.com/en-gb/home/injuries-and-poisoning/fractures/overview-of-fractures (accessed: September 12 2021).

Throckmorton TW. Fractures (Broken Bones). 2021. https://orthoinfo.aaos.org/en/diseases--conditions/fractures-broken-bones/ (accessed: September 16, 2021)

Melton LJ, Thamer M, Chan JK et al. Fractures attributable to osteoporosis: report from the National Osteoporosis Foundation. J Bone Miner Res. 1997; 12(1), pp. 16–23. https://doi.org/10.1359/JBMR.1997.12.1.16 

Mitchell SAT, Majuta LA, Mantyh PW. New insights in understanding and treating bone fracture pain. 2018; 16(4):325-3321. https://doi.org/10.1007/s11914-018-0446-8.

National Institute for Health and Care Excellence. Fractures (non-complex): assessment and management. 2016a. https://www.nice.org.uk/guidance/ng38  (accessed September 16 2021)

National Institute for Health and Care Excellence. Fractures (complex): assessment and management. 2016b. https://www.nice.org.uk/guidance/ng37 (accessed September 12, 2021)

Rizzoli, R, Body J-J, Brandi M-L et al. Cancer-associated bone disease. Osteoporosis Int. 2013; 24(12):2929–2953. https://doi.org/10.1007/S00198-013-2530-3

Sheen JR, Garla VV. Fracture Healing Overview. In: StatPearls [Internet]. Treasure