Contents · 12 sections
In a nutshell. A fracture is a disruption of bone continuity. They are classified by mechanism (direct/indirect), fracture line pattern (transverse, oblique, spiral, comminuted), displacement, location (diaphysis, metaphysis, epiphysis, intra-articular), and by AO/OTA (segment - type A/B/C). Open fractures are classified using Gustilo-Anderson I–IIIC. Principles: early reduction, stable fixation, preservation of blood supply, functional treatment (4 AO principles). Consolidation: 4–6 weeks (children) to 8–16 weeks (adults). Complications: compartment syndrome, fat embolism, nonunion, avascular necrosis, PE.
1. Classification
By etiology
- Traumatic (direct/indirect mechanism).
- Pathological (tumor, metastases, osteoporosis, multiple myeloma).
- Stress/fatigue (repetitive microtrauma).
By skin integrity
- Closed.
- Open (Gustilo-Anderson):
- — Type I: wound < 1 cm, clean, minimal soft tissue damage.
- — Type II: wound 1–10 cm, moderate damage.
- — IIIA: significant damage, but bone is covered by soft tissues.
- — IIIB: extensive damage with bone exposure, requires flap coverage.
- — IIIC: + major arterial injury.
By fracture line pattern
- Transverse — direct impact.
- Oblique — angular force.
- Spiral — rotational mechanism.
- Comminuted (multifragmentary) — high-energy trauma.
- Impacted — axial loading (femoral neck, calcaneus).
- Compression — vertebrae in a fall.
- Avulsion — tendon/ligament traction.
- Greenstick and buckle — in children (subperiosteal).
By displacement
- Undisplaced.
- Displaced: length, width, angular, rotational.
By location
- Diaphyseal, metaphyseal, epiphyseal, intra-articular.
- In children — Salter-Harris types I–V epiphyseal injuries.
2. AO/OTA Classification
- Digital code of the segment (e.g., femur — 3, proximal segment — 3.1, diaphysis — 3.2, distal — 3.3).
- Type: A — simple, B — wedge, C — complex/multifragmentary.
- Groups and subgroups by severity.
- Used for prognosis and treatment planning.
3. Clinical presentation
- Definite signs: crepitus, pathological mobility, visible deformity, limb shortening.
- Probable signs: pain, swelling, hematoma, impaired function.
- Always assess the neurovascular bundle distal to the fracture (pulse, capillary refill, sensation, motor function).
4. Examination
- Radiography in 2 projections including adjacent joints.
- CT — intra-articular fractures, pelvis, spine, calcaneus.
- MRI — stress fractures, occult fractures (femoral neck), ligament-capsule complex injuries.
- Ultrasound — in children, uncomplicated forearm fractures.
- Scintigraphy — stress fractures, multiple metastases.
- Angiography/CT angiography — when vascular injury is suspected.
5. AO Principles
- Anatomic reduction — especially for intra-articular fractures.
- Stable fixation.
- Preservation of blood supply to bone fragments and soft tissues.
- Early active mobilization of muscles and joints.
6. Treatment methods
Conservative
- Reduction (closed reduction, manipulation, or traction).
- Immobilization: plaster or synthetic cast, braces, orthoses.
- Skeletal traction (femur, lower leg in adults as a temporary measure).
- Functional treatment (rib fractures, vertebral compression fractures).
Surgical
- Internal fixation (ORIF): plates, screws, locked intramedullary nail.
- Transosseous osteosynthesis: Ilizarov apparatus, external fixators (indicated for open, infected, comminuted fractures).
- Arthroplasty for femoral neck fractures in the elderly.
- MIPO (minimally invasive plate osteosynthesis) — tissue-sparing technique.
- Damage control orthopaedics — temporary external fixation in polytrauma, followed by definitive osteosynthesis.
7. Indications for surgery
- Open fractures.
- Irreducible or unstable fractures.
- Intra-articular fractures with displacement.
- Pathological fractures.
- Neurovascular bundle injury.
- Femoral neck fractures in the elderly.
- Polytrauma.
- Need for early mobilization (elderly, professional athletes).
8. Treatment of open fractures
- Antibiotic therapy within the first 3 hours: cefazolin 2 g × 3 (types I–II), + gentamicin or ciprofloxacin for type III, + clindamycin/metronidazole in case of soil contamination (C. perfringens).
- Tetanus toxoid.
- Emergency surgical debridement within 6 hours (classic rule); modern data allow 12–24 hours without an increased risk of infection if proper antibiotic therapy is administered.
- Primary fixation — external fixator or nail (depending on the clinical situation).
- Early soft tissue closure within 7 days — reduces the risk of deep infection.
9. Complications
Early
- Traumatic/hemorrhagic shock.
- Fat embolism syndrome (24–72 hours after long bone fractures): hypoxemia, petechial rash, altered mental status.
- Pulmonary embolism (PE), deep vein thrombosis (DVT).
- Compartment syndrome: 5 Ps — pain (out of proportion), pallor, paresthesias, pulselessness (late), paralysis; ΔP < 30 mmHg → fasciotomy.
- Vascular/nerve injury.
- Infection.
Late
- Delayed union, pseudoarthrosis, nonunion.
- Malunion.
- Avascular necrosis (femoral neck, scaphoid, talus).
- Post-traumatic osteoarthritis.
- Volkmann's contracture.
- Complex regional pain syndrome (CRPS, Sudeck's atrophy).
- Chronic osteomyelitis.
- Myositis ossificans.
10. Healing timeframes
| Localization | Adults (weeks) | Children (weeks) |
|---|---|---|
| Finger phalanges | 3–4 | 2–3 |
| Forearm | 6–10 | 4–6 |
| Humerus (shaft) | 8–12 | 4–6 |
| Femur (shaft) | 12–16 | 6–8 |
| Femoral neck | 12–24 (risk of nonunion) | — |
| Tibia (shin) | 12–16 | 6–10 |
| Clavicle | 4–6 | 3–4 |
| Ribs | 3–4 | 2–3 |
| Pelvis | 8–12 | — |
11. Specifics in the elderly
- Femoral neck fractures — arthroplasty within the first 48 hours to reduce mortality.
- Perioperative osteoporosis screening (DEXA).
- Early mobilization, DVT prophylaxis (LMWH for 28–35 days).
- Treatment of osteoporosis (bisphosphonates, denosumab) after a fracture.
12. FAQ
What is the "6-hour rule" in open fractures?
Traditionally, surgical debridement within the first 6 hours to reduce infection. Modern studies have shown that with timely antibiotic therapy, the "window" expands to 12–24 hours without an increase in complications.
What is the difference between a pseudarthrosis and delayed union?
Delayed union means healing is progressing, but slower than normal (1.5–2 times longer). Pseudarthrosis (nonunion) means no signs of healing after 6–9 months; surgery, bone grafting, and stimulation are required.
Why are femoral neck fractures in the elderly operated on immediately?
A delay of > 48 hours increases mortality by 30%. Early arthroplasty allows for mobilization and reduces pulmonary embolism, pneumonia, and pressure ulcers.
What is the "coconut and palm principle"?
Fracture of the base of the 5th metatarsal during an inversion injury — a variant of the Jones fracture; poor blood supply, high risk of nonunion; screw fixation is often required.
How to detect an occult femoral neck fracture?
MRI is the method of choice when radiography is negative despite clinical signs (inability to bear weight, hip pain). An alternative is bone scintigraphy after 48 hours.
See also: Dislocations · Osteoporosis · Polytrauma · Compartment syndrome · Surgery Catalog