A fracture refers to a disruption or loss of bone integrity caused by external force, occasionally associated with bone disease. Clinical manifestations include bleeding, pain, swelling, and limited mobility. Minor fractures generally have a good prognosis, while more severe fractures may impair function in the affected area or even lead to death. Treatment options include external fixation or surgical internal fixation.
Clinical classification
1. Classification according to the cause of disease
(1) Traumatic fracture: A fracture caused by direct or indirect violence on the injured part.
(2) Pathological fracture: fracture caused by bone destruction due to osteomyelitis, bone tumors, etc., and fracture caused by slight external force.
2. Classification based on whether the fracture site is connected to the outside world
(1) Closed fracture: The skin or mucous membrane at the fracture site is intact and not connected to the outside world.
(2) Open fracture: The skin or mucous membrane near the fracture is broken, and the fracture site is connected to the outside world.
3. Classification according to the fracture line
(1) Incomplete fracture: The integrity or continuity of the bone is only partially interrupted, such as cleft fracture and greenstick fracture.
(2) Complete fracture: The fracture line passes through the periosteum and bone, completely separating the fracture ends.
4. Classification based on the stability of the fracture end
(1) Stable fractures: Those that are not easily displaced after reduction and appropriate external fixation are called stable fractures, such as fissure fractures, greenstick fractures, impacted fractures, and transverse fractures.
(2) Unstable fractures: Those that are prone to re-displacement after reduction are called unstable fractures, such as oblique fractures, spiral fractures, comminuted fractures, etc.
5. Classification according to the anatomical location of the fracture on the bone
(1) Shaft fracture: refers to the fracture of the diaphysis of a long tubular bone.
(2) Intra-articular fracture: a fracture in which the fracture line extends to the joint surface (joint capsule).
(3) Endoaxial fracture: refers to the fracture of the end of the long bone. When the fracture line extends to the articular surface, it is an intra-articular fracture.
(4) Fracture-dislocation: fracture and dislocation of adjacent joints occur simultaneously.
(5) Skeletal injury: refers to the involvement of children’s bones.
(6) Cartilage fracture: It is a special type of intra-articular fracture and requires arthroscopy or MRI examination to be diagnosed.
Epidemiology
Contagious
Not contagious.
High-risk population
There is no special population.
Causes
Overview
A fracture is an interruption or loss of bone integrity or continuity caused by trauma, and is often related to direct violence, indirect violence, muscle strain, accumulated strain, and bone disease.
Basic cause
1. Direct violence
Fractures occur at the site of direct impact of force.
2. Indirect violence
Violence causes fractures at a distance through conduction, leverage, or rotation.
3. Muscle tension
A sudden, violent contraction of a muscle can break the bone where the muscle is attached.
4. Accumulated strain
Long-term, repeated, mild direct or indirect injuries (such as long-distance marches) can cause fractures at a certain point in the bone. The fractures are not displaced, but heal slowly.
Risk factors
Diseases such as osteomyelitis and bone tumors can cause osteoporosis, making bones brittle and causing fractures during normal activities or when subjected to slight external forces.
symptom
Overview
Minor fractures generally only cause symptoms such as local pain, swelling, and limited movement, while severe fractures and multiple fractures can also cause symptoms such as fever and shock.
Typical symptoms
1. Pain
Severe pain occurs at the fracture site, especially when the affected limb is moved, accompanied by obvious tenderness.
2. Local swelling
When a bone is fractured, the blood vessels in the bone marrow, periosteum and surrounding tissues rupture and bleed, forming a hematoma at the fracture site, and edema caused by soft tissue damage, resulting in local swelling of the affected area.
3. Dysfunction
Local swelling or pain limits the movement of the affected limb. If it is a complete fracture, the injured limb may lose its function completely.
4. Bone crepitus or bone friction
Crepitus or grating of bones may be produced when the two fractured bones rub against each other.
Associated symptoms
Body temperature is generally normal after a fracture, but fractures with heavy bleeding, such as femoral fractures or pelvic fractures, may be accompanied by a low-grade fever as the hematoma is absorbed, but generally does not exceed 38°C. High fever after an open fracture should raise the possibility of infection.
complication
1. Early complications
(1) Shock
Caused by severe trauma or fracture leading to massive bleeding or damage to important organs.
(2) Fat embolism syndrome
In adults, this condition occurs when fat droplets from fractures enter ruptured venous sinuses, potentially leading to pulmonary and cerebral fat embolism. Simultaneously, poor lung perfusion can lead to pulmonary hemorrhage, atelectasis, and hypoxemia. Clinically, respiratory insufficiency and cyanosis may occur, with chest radiographs demonstrating extensive pulmonary consolidation. Arterial hypoxemia can cause irritability, lethargy, and even coma and death.
(3) Damage to important internal organs
When the ribs are fractured, the fracture ends can damage the intercostal blood vessels and lung tissue, resulting in pneumothorax, hemothorax or hemopneumothorax, causing severe breathing difficulties; bladder and urethra injury: caused by pelvic fractures, urine extravasation causes pain and swelling in the lower abdomen and perineum, as well as hematuria and difficulty urinating; it may also cause damage to organs such as the liver, spleen, and rectum.
(4) Damage to important surrounding tissues
Supracondylar femoral fractures can injure the popliteal artery distally; proximal tibial fractures can injure the anterior or posterior tibial arteries; and extension-type supracondylar humeral fractures can injure the brachial artery proximally. Fractures at the junction of the middle and lower thirds of the humerus are particularly susceptible to injuring the radial nerve, which runs closely along the humerus. Fractures and dislocations of the cervical and thoracolumbar spine can be complicated by spinal cord injury.
(5) Compartment syndrome
This syndrome is a series of early-stage complications resulting from acute muscle and nerve ischemia, commonly seen on the volar forearm and lower leg. It is often caused by increased volume within the fascial compartment following a traumatic fracture or by overly tight external bandages and localized compression. Myoglobinuria is often present, and treatment should include adequate fluid replacement to promote urination. If compartment pressure exceeds 30 mmHg, prompt fasciotomy and decompression surgery are indicated.
2. Late complications
(1) Hypostatic pneumonia
It mainly occurs in patients who are bedridden for a long time due to fractures, especially the elderly.
(2) Pressure ulcers
Severe traumatic fractures, prolonged bed rest, and pressure on bony protrusions can lead to localized blood circulation impairment, making pressure sores more likely to develop. Paraplegics are particularly susceptible to pressure sores, which are not only difficult to heal but also a source of systemic infection.
(3) Deep vein thrombosis of the lower limbs
It is more common in pelvic fractures or lower limb fractures. Long-term immobilization of the lower limbs leads to slow venous blood return, which can easily lead to thrombosis.
(4) Infection
Open fractures, especially those with heavy contamination or severe soft tissue damage, can be susceptible to infection if incomplete debridement, residual necrotic tissue, or poor soft tissue coverage, leaves bone exposed. Improper treatment can also lead to suppurative osteomyelitis.
(5) Traumatic ossification
Also known as myositis ossificans, this condition occurs when a sprain, dislocation, or fracture near a joint causes the periosteum to peel away, forming a subperiosteal hematoma. This hematoma then becomes organized and ossifies extensively within the soft tissue surrounding the joint, leading to severe joint dysfunction. This condition is most common in the elbow joint.
(6) Traumatic arthritis
Intra-articular fractures and articular surfaces are destroyed, and anatomical reduction cannot be achieved. After bone healing, the articular surface becomes uneven, and long-term wear causes pain when the joint bears weight.
(7) Joint stiffness
If the affected limb is immobilized for a long time, venous and lymphatic return will be poor, fibrous adhesions will occur, and the joint capsule and surrounding muscles will contract, resulting in joint movement disorders.
(8) Acute bone atrophy
This is painful osteoporosis near joints caused by injury, also known as reflex sympathetic osteodystrophy. It often occurs after fractures of the hands or feet, with typical symptoms including pain and vasomotor disturbances. The pain is disproportionate to the severity of the injury, exacerbated by movement of nearby joints, and can be accompanied by a localized burning sensation. Early symptoms include increased skin temperature, edema, and accelerated hair and nail growth, followed by hypothermia, excessive sweating, smooth skin, and hair loss. The hands or feet can become swollen, stiff, cold, and slightly cyanotic, persisting for several months.
(9) Ischemic bone necrosis
A fracture can disrupt the blood supply to one end of the fracture, causing avascular necrosis of that end. Common examples include avascular necrosis of the proximal end of the wrist following a scaphoid fracture and avascular necrosis of the femoral head following a femoral neck fracture.
(10) Ischemic muscle contracture
It is one of the most serious complications of fractures and a serious consequence of improperly managed compartment syndrome. Once it occurs, it is difficult to treat, with minimal success, often resulting in severe disability. Typical deformities are claw hands or feet.
examine
Scheduled inspection
Patients experiencing bleeding, pain, swelling, or limited mobility after trauma should seek medical attention promptly. The doctor will first perform a physical examination of the affected area. If positive signs are found, further diagnosis may include routine blood tests, X-rays, CT scans, and, if necessary, MRIs to assess surrounding tissue damage.
Physical examination
1. Visual examination
The doctor will observe whether the affected limb has shortening, angulation, or rotational deformity, whether the affected limb has swelling, shiny skin, blisters, and subcutaneous ecchymosis, and whether the part of the limb that cannot move under normal circumstances has abnormal movement.
2. Palpation
Doctors will compress the fracture from a distance toward the fracture site, detecting localized tenderness at or beyond the fracture site. This helps diagnose deep fractures and their location. For example, in the case of a pelvic fracture, gently squeezing the two iliac wings with both hands may cause pain at the fracture site. Percussion of the affected area, if tenderness is present, can be valuable in detecting intra-articular fractures such as impacted femoral neck fractures and scaphoid fractures.
3. Neurovascular examination
Doctors will examine motor and sensory function below the injured area to determine the presence, extent, and severity of nerve damage. Radial nerve damage is most common after radial shaft fractures. For fractures above the wrist or ankle, doctors will check for pulses and weakness in the radial or dorsalis pedis arteries to rule out vascular injuries in the extremities.
Laboratory tests
If there is heavy bleeding, a routine blood test may show a decrease in hemoglobin. Depending on the severity of the fracture, the white blood cell count may increase or slightly increase 24 hours later, and the erythrocyte sedimentation rate may also increase slightly.
Imaging examinations
1. X-ray examination
It is the first and routine examination for fractures. Even if a fracture is clinically evident, plain x-rays are necessary to help determine the fracture type and displacement of the fracture ends, providing important guidance for fracture treatment.
2. CT
CT examinations are crucial for intra-articular fractures and complex fractures (such as pelvic and hip fractures). CT or CT reconstruction can accurately determine the size and number of fracture fragments, as well as the damage and degree of articular surface indentation, providing a reference for preoperative planning and selection of surgical approach.
3. Magnetic resonance imaging (MRI)
MR examination can determine the extent of soft tissue injury, such as the degree of spinal cord injury and its relationship with vertebral fractures, damage to the ligaments in the shoulder, hip and knee joints, and the status of the joint capsule. It can also be used to diagnose some occult fractures.
diagnosis
Diagnostic principles
Based on clinical manifestations, the diagnosis is confirmed by the presence of any one of the characteristic fracture signs (deformity, abnormal movement, or a grinding or crepitating sensation). However, some fractures, such as cleft fractures, impacted fractures, spinal fractures, and pelvic fractures, lack these three typical fracture signs and require a definitive diagnosis based on plain x-rays, CT, or MRI.
Diagnostic basis
1. Medical history
There is a clear history of trauma.
2. Physical signs
Specific signs of a fracture include deformity, abnormal movement, and a crepitus or rubato sensation.
3. X-ray examination
A fracture line is visible.
Differential diagnosis
Fractures with deformity should be differentiated from joint dislocations.
treat
Treatment principles
Fracture treatment primarily involves reduction, fixation, and rehabilitation. Severe or open fractures require emergency treatment, such as shock treatment and hemostasis. Internal fixation generally requires additional fixation with a plaster bandage.
Symptomatic treatment
1. Debride open wounds. Clean and disinfect the contaminated wounds, then remove the wound edges, remove foreign matter, and remove necrotic and lifeless tissues to make them clean wounds.
2. For bleeding wounds, apply pressure bandage and use a tourniquet to stop bleeding if necessary.
Acute treatment
The acute stage of fracture mainly refers to severe fractures or open fractures, such as pelvic fractures, femoral fractures, fractures piercing the skin, etc. Patients may experience symptoms such as shock and heavy bleeding.
1. Save lives
First, check the patient’s general condition. For patients in shock or coma, blood transfusion, infusion and other supportive treatments should be given in time. At the same time, keep the patient’s airway open and perform tracheal intubation or tracheotomy when necessary.
2. Protect the affected limb
(1) Most wounds can be stopped by applying pressure bandages. For bleeding from large blood vessels, a tourniquet can be used. It is best to use an inflatable tourniquet, and the pressure and time used should be recorded. The wound should be bandaged with sterile dressings or clean cloths to reduce re-contamination. If the fracture end has protruded from the wound and is contaminated, and has not compressed important blood vessels or nerves, it should not be repositioned to avoid bringing dirt deeper into the wound.
(2) Proper fixation is an important measure for first aid in fracture treatment. All suspected fractures should be treated as fractures. For closed fractures, avoid excessive movement of the affected limb during first aid to avoid increasing pain. If the affected limb is severely swollen, the sleeves and trouser legs of the affected limb can be cut open with scissors to relieve pressure. If the fracture is obviously deformed and there is a risk of penetrating soft tissue or damaging nearby important blood vessels and nerves, appropriate traction can be applied to the affected limb, and then fixation can be performed after it stabilizes.
General treatment
1. Small splint
Suitable for closed, non-displaced, stable fractures of the limbs.
2. Orthopedic fixation brace
It is suitable for closed stable fractures of the limbs, especially stable fractures of the limbs, greenstick fractures and joint soft tissue injuries.
3. Plaster bandage
It is suitable for use as auxiliary external fixation after debridement and suture of open fractures, open reduction and internal fixation of fractures in certain parts of the body (such as intramedullary nail or plate screw fixation of femoral fractures), maintaining the corrected position after deformity correction, after arthrodesis surgery, and fixation of limbs affected by suppurative arthritis and osteomyelitis.
4. Fixation of head, neck and abduction brace
The former is mainly used for cervical spine injuries, while the latter is used for fractures around the shoulder joint, humeral fractures and brachial plexus injuries.
5. Continuous traction
Continuous traction is suitable for cervical fracture and dislocation, femoral fracture, and tibial fracture.
Drug treatment
1. Analgesia
Morphine, tramadol, etc. can be used for patients with severe postoperative pain.
2. Anti-infection
(1) Broad-spectrum antibiotics, usually first- or second-generation cephalosporins, are recommended.
(2) Aminoglycoside antibiotics should be added to injuries that are at risk of serious contamination by Gram-negative bacteria.
(3) If there is a possibility of anaerobic infection, it is recommended to use high-dose penicillin or antibiotics that are sensitive to anaerobic bacteria.
Related drugs
Morphine, tramadol, penicillin
Surgical treatment
1. Open reduction and internal fixation
(1) Indications: ① Patients with soft tissue embedded in the fracture ends or failed manual reduction; patients with intra-articular fractures whose alignment is poor after manual reduction, affecting joint function. Patients whose functional reduction is seriously affected by manual reduction and external fixation failing to meet the functional reduction standard. ② Patients with fractures complicated by vascular and nerve damage, and open fractures cannot be fixed with external fixation. ③ Patients with multiple fractures. In order to facilitate care and treatment and prevent complications, open reduction can be performed at appropriate locations. ④ Old displaced fractures. ⑤ Fractures that require anatomical alignment due to appearance, or fractures that require internal fixation and early mobilization due to occupational needs, can all be treated with open reduction as appropriate.
(2) Internal fixation is the use of metal internal fixators, such as bone plates, screws, compression plates or locking intramedullary nails, to fix the reduced fracture.
2. Amputation
(1) Indications: ① Complete destruction of the tibial nerve in adults; crush injury with warm ischemia time >6 hours. ② Severe multiple injuries; severe ipsilateral injuries; anticipated multiple soft tissue lengthening and reconstruction.
(2) It is also necessary to evaluate the four aspects of bone and soft tissue injury, shock, local ischemia and age.
3. Bone grafting
(1) Indications: ① For patients with extensive skin, subcutaneous tissue, and muscle injuries, combined with vascular and nerve damage, severe wound contamination, and open fractures with comminuted and segmental defects, if early bone induration is not seen 3-6 weeks after surgery, bone grafting should be performed as soon as possible. ② If early bone induration is not seen for more than 12 weeks after surgery, internal fixation failure may occur and bone grafting is necessary.
(2) The timing depends on the location and severity of the soft tissue defect.
Traditional Chinese Medicine treatment
1. The principle of Chinese medicine for the application of internal and external medications is to use medications according to the various stages of the fracture healing process, and then combine it with systemic symptoms to diagnose and treat.
2. Early on, Qi-activating and blood-activating methods should be used. During the initial callus formation phase, blood-regulating and blood-nourishing drugs should be used. During the shaping phase, the focus should be on strengthening the body, Qi-invigorating, and tendon-strengthening. For the first two weeks, topical ointments based on the principles of promoting blood circulation and dispersing stasis, and harmonizing blood and promoting new blood, should be used. In the later stages, when the fracture has achieved clinical healing, fumigation and washing drugs can be used. Both internal and external medications can promote fracture healing.
3. Medication cannot be divided into clear categories. It must be combined with clinical characteristics and applied flexibly according to the specific circumstances.
Treatment costs
There may be significant individual differences in treatment costs, and the specific costs are related to the selected hospital, treatment plan, medical insurance policy, etc.
Prognosis
General prognosis
The healing of fractures is related to age, physical health, type and number of fractures, blood supply to the affected area, and whether there is infection. The general prognosis is good.
Hazards
Fractures can cause physical activity disorders and deformities, and in some severe cases, even death.
Self-healing
Greenstick fractures in children and non-displaced fractures in adults can heal on their own with proper immobilization.
Curative
Fractures can be cured through active reduction, fixation and rehabilitation training.
Cure rate
The vast majority are curable.
sequelae
Local muscle pain, swelling, stiffness and functional impairment.
daily
Overview
Fractures have a great impact on patients’ daily activities and are prone to cause negative emotions, which should be adjusted and channeled. During the rehabilitation process, patients should maintain a good attitude, proceed step by step, and avoid further injury.
Psychological care
Fractures severely impact patients physically and mentally, and they often worry about whether healing will affect their daily activities and ability to function. This can lead to depression, anxiety, tension, and fear, especially for those who are bedridden for extended periods. Family members should accompany patients, talk with them, offer comfort and encouragement, and help them build confidence in overcoming the illness and actively cooperate with treatment.
Life Management
1. Avoid fatigue and avoid excessive and vigorous activities of the affected limb.
2. Pay attention to the cleanliness of the affected area, and disinfect it on time if there is external fixation.
3. Wear breathable clothes and keep the affected area ventilated and dry.
Follow-up Instructions
Follow the doctor’s instructions for a follow-up visit to evaluate the recovery of the fracture. Routine X-ray examinations are performed during the follow-up visit, and CT examinations may also be performed depending on the severity of the injury.
Special care
1. Functional exercise
It is an important component of fracture treatment and can quickly restore the affected limb to normal function. Under the guidance of medical personnel, it should follow a combination of static and dynamic, active and passive movements, and early functional exercise to promote fracture healing and functional recovery and prevent complications.
2. Functional exercise methods
(1) In the early stages of a fracture (within 1 to 2 weeks after injury), the affected limb is locally swollen and painful, and the fracture ends are prone to further displacement. The soft tissue is in the repair stage. The main form of functional exercise during this period is to allow the muscles of the affected limb to contract and relax. For example, in the case of a forearm fracture, slight palm grip and finger flexion and extension exercises can be performed. The upper arm only requires muscle contraction and relaxation, and the wrist and elbow joints are not active. Functional exercises should be performed on all other joints in the body. The purpose of functional exercise during this period is to promote blood circulation in the affected limb, reduce swelling, prevent muscle atrophy, and avoid joint stiffness.
(2) In the middle stage of fracture (after two weeks), the swelling of the affected limb subsides, the local pain gradually disappears, the soft tissue damage has been repaired, the fracture ends have been connected by fibers, and callus is gradually forming, and the fracture site is becoming more stable. In this stage, in addition to continuing to relax and contract the muscles of the affected limb, the upper and lower joints of the fracture site are gradually moved with the help of the healthy limb or medical staff. The movements should be slow, and the range of motion should be gradually increased. When the patient is close to clinical healing, the number of movements should be increased, and the range of motion and strength should be increased. For example, with the support of an external fixator, patients with tibia and fibula fractures can freely extend and flex the joints of the lower limbs. For example, with a femoral fracture, with a small splint fixation and continuous traction, they can perform arm support and hip lifting, hip and knee extension and flexion, and other activities.
(3) In the late stage of fracture (after clinical healing of the fracture), the main form of functional exercise is to strengthen the active movement of the joints of the affected limb so that the joints can quickly return to their normal range of motion.
diet
Dietary adjustment
The diet should be nutritionally balanced, and appropriately increasing vitamin A, protein, etc. will help promote fracture healing.
Dietary recommendations
1. In the early stage of fracture, the diet should be light, and it is suitable to eat fresh fruits and vegetables, soy products, fish soup, etc.
2. After treatment, you can increase nutrition in your diet appropriately and supplement vitamin A and protein to help the growth of callus.
3. It is appropriate to eat easily digestible food. You can eat bananas, stomach-strengthening and digestion-promoting tablets, etc. after meals to promote gastrointestinal digestion and absorption.
Dietary taboos
1. Avoid spicy and irritating foods.
2. Avoid excessive drinking.
prevention
Preventive measures
This disease is mainly related to trauma and bone diseases. Wearing seat belts when using public transportation and using protective equipment during outdoor sports can reduce trauma. Middle-aged and elderly people should pay attention to supplementing vitamin D and calcium to strengthen bones.
Medical Guide
Emergency (120) indications
1. Open fracture injury occurs;
2. Shock after trauma;
3. Other critical situations occur.
All of the above require urgent treatment. Go to the emergency department in time and call the emergency number if necessary.
Outpatient indications
1. Continuous pain in the affected area after external force;
2. Restriction of physical activity;
3. Other severe, persistent or progressive symptoms and signs occur.
All of the above require prompt medical consultation.
Treatment department
If the above emergency occurs, you should go to the emergency department in time; if the symptoms are mild, you can go to the orthopedics department for treatment.
Medical preparation
1. Make an appointment in advance and bring your ID card, medical insurance card, medical card, etc.
2. When going to the doctor, try to keep the affected limb immobilized to avoid worsening the condition.
3. If you have had medical treatment recently, please bring relevant medical records, examination reports, laboratory test results, etc.
4. If you have taken some medicine to relieve symptoms recently, you can bring the medicine box with you.
5. Family members can be arranged to accompany the patient to seek medical treatment.
6. Patients can prepare a list of questions they want to ask in advance.
Questions your doctor may ask
1. What discomforts do you currently have?
2. How long have you been experiencing this condition?
3. Did you have any trauma before your symptoms appeared?
4. Have your symptoms gotten worse or better since you became ill? Have you had similar symptoms before?
5. Have you ever received treatment before? How was it treated? What was the effect?
6. Are you taking any medications?
What questions can patients ask?
1. Is my condition serious? Can it be cured?
2. What treatment do I need? Do I need to be hospitalized? How long will it take to recover?
3. Are there any risks associated with these treatments?
4. Is surgery necessary?
5. What tests do I need? Are they covered by medical insurance?
6. I have other diseases. Will this affect my treatment?
7. How should I take care of myself after returning home?
8. Do I need follow-up examinations? How often?