Fracture — Causes, Types, Diagnosis & Treatment Guide — Symptoms, Causes & Treatment | MyMedicPlus

A fracture is a complete or partial discontinuity in the cortex of a bone caused by a force exceeding the bone's mechanical strength. Fractures are among the most common injuries managed in emergency departments worldwide, with an estimated 178 million new fractures annually. They are classified by cause (traumatic, stress/fatigue, pathological), pattern (transverse, oblique, spiral, comminuted, segmental), displacement and angulation, integrity of overlying skin (open/compound versus closed), and anatomical location. Open fractures (skin breached, exposing bone or haematoma to environment) are surgical emergencies requiring immediate irrigation and debridement within 6 hours. Stress fractures result from repetitive loading exceeding the bone's remodelling capacity — common in military recruits and distance runners (metatarsal, tibia, femoral neck). Pathological fractures occur through abnormal bone weakened by osteoporosis, metastatic cancer, primary bone tumours, Paget's disease, or infection. Hip fractures in the elderly carry 20-30% one-year mortality and represent a major public health burden.

Traumatic fractures result from acute mechanical forces: falls (the most common cause in children and the elderly), road traffic accidents, sports injuries, and direct blows. Low-energy falls from standing height in the elderly typically cause wrist (Colles'), hip (femoral neck/intertrochanteric), and vertebral compression fractures — reflecting underlying osteoporosis. High-energy trauma causes complex fractures in any bone. Stress fractures arise from repetitive submaximal loading — risk factors include sudden increases in training volume, hard training surfaces, nutritional deficiency (low caloric intake, vitamin D and calcium deficiency), female athlete triad (energy deficiency, menstrual dysfunction, low bone density), and osteoporosis. Pathological fracture risk factors: osteoporosis (T-score below -2.5 on DXA scan; FRAX score above intervention threshold), long-term corticosteroid use, metastatic bone disease (breast, prostate, lung, kidney, thyroid primaries most commonly metastasise to bone), primary bone tumours (osteosarcoma, Ewing's sarcoma, chondrosarcoma), multiple myeloma, and Paget's disease. Paediatric considerations: children's bones are more flexible (greenstick and torus/buckle fractures are unique to children) and heal faster; growth plate (physeal) injuries are classified by the Salter-Harris system and require careful management to avoid growth disturbance.

Classic fracture symptoms include localised pain at the injury site, swelling and soft tissue bruising (ecchymosis — appearing 24-48 hours after injury), deformity or abnormal limb position, crepitus (grating sensation) on movement, loss of function, and point tenderness on palpation directly over the fracture site. Open fractures present with visible bone or wound communicating with the fracture haematoma — risk of infection and neurovascular compromise requires emergency management. Neurovascular assessment is essential: check distal pulse, capillary refill, sensation, and motor function distal to the fracture. Absent pulses suggest vascular injury (e.g., posterior knee dislocation injuring the popliteal artery). Compartment syndrome — a limb-threatening emergency — presents with the 6 Ps: Pain out of proportion to injury (especially with passive muscle stretch), Pressure (tensely swollen compartment), Paraesthesia (nerve ischaemia), Paralysis (motor loss — late sign), Pallor, and Pulselessness (very late sign). Vertebral fractures may present with sudden back pain after minimal trauma in the elderly (osteoporotic compression fracture) or neurological compromise (spinal cord injury). Hip fractures present with inability to bear weight and shortening and external rotation of the leg.

Plain X-ray in two perpendicular views is the first-line investigation for most suspected fractures — it confirms the fracture, characterises the pattern, assesses displacement, shortening, and angulation, and identifies associated joint involvement. The Ottawa Ankle Rules and Ottawa Knee Rules are validated clinical decision tools that reduce unnecessary X-rays by identifying low-risk patients who do not require imaging. CT scan provides superior three-dimensional fracture mapping for complex fractures (tibial plateau, calcaneus, pilon, acetabulum, intra-articular fractures, vertebral injury), surgical planning, and detection of subtle fractures missed on plain X-ray. MRI is the gold standard for stress fractures, occult fractures (scaphoid, hip — where X-ray may be negative in the first 72 hours), bone marrow pathology, and soft tissue injuries (ligament, tendon, cartilage). Bone scintigraphy (technetium-99m scan) detects stress fractures when MRI is unavailable. For suspected pathological fractures: staging investigations include CT chest/abdomen/pelvis, bone scan, serum protein electrophoresis (myeloma), PSA, bone-specific alkaline phosphatase, and tissue biopsy where indicated. Bone mineral density (DXA scan) is indicated in all fragility fractures to quantify osteoporosis and guide bisphosphonate therapy.

Fracture management follows the principles of reduction (restoring anatomical alignment), immobilisation (maintaining alignment during healing), and rehabilitation (restoring function). Closed reduction with cast or splint immobilisation is appropriate for undisplaced or minimally displaced fractures not involving joint surfaces — Colles' wrist fractures, ankle fractures, metacarpal fractures. Surgical fixation is indicated for: unstable fractures with unacceptable displacement; fractures involving joint surfaces (intra-articular); fractures of the femoral shaft (intramedullary nail), hip (dynamic hip screw for intertrochanteric; hemiarthroplasty or total hip replacement for displaced femoral neck fractures in the elderly); open fractures (external fixation or internal fixation after wound debridement); non-union or malunion; and most fractures in patients with osteoporosis where cast is unlikely to maintain reduction. Common surgical techniques: open reduction and internal fixation (ORIF) with plates and screws; intramedullary nailing for long bone fractures (femur, tibia); external fixation for open or contaminated fractures; arthroplasty for severely comminuted periarticular fractures. Bone healing typically takes 6-8 weeks for upper limb fractures, 12-16 weeks for lower limb weight-bearing bones. Medical treatment: adequate calcium (1000-1200 mg/day) and vitamin D (800-1000 IU/day); bisphosphonates or denosumab for osteoporosis-related fragility fractures; liaison fracture service review reduces re-fracture rate by 50%.

Open (compound) fractures carry high risk of osteomyelitis (bone infection), potentially requiring months of antibiotics, multiple surgeries, and occasionally amputation. Fat embolism syndrome — fat droplets entering the bloodstream after long bone fractures — causes respiratory failure, confusion, and petechial rash within 24-72 hours. Compartment syndrome from post-fracture swelling, if not treated with emergency fasciotomy, causes permanent muscle necrosis and limb loss. Avascular necrosis of the femoral head complicates 15-30% of displaced femoral neck fractures. Hip fractures in elderly patients carry 20-30% one-year mortality from complications including pulmonary embolism and pneumonia. Malunion (fracture heals in incorrect position) causes long-term functional impairment.

Osteoporosis management is the cornerstone of fragility fracture prevention: adequate calcium and vitamin D intake throughout life, weight-bearing exercise, smoking cessation, and pharmacological treatment (bisphosphonates, denosumab, teriparatide for severe osteoporosis). Falls prevention programmes reduce hip fracture incidence in the elderly by 20-30%: balance and strength training, home hazard assessment, vision correction, medication review (sedatives, antihypertensives contributing to orthostatic hypotension), and hip protectors for very high-risk individuals. Multidisciplinary Fracture Liaison Services (FLS) ensure systematic identification and treatment of osteoporosis after first fragility fracture, reducing refracture rates. Sports injury prevention: adequate warm-up, progressive training load increases, appropriate footwear, and maintaining sufficient caloric intake to support bone remodelling in athletes. Helmet and protective equipment use in contact sports and cycling reduces skull and extremity fractures. Vitamin D and calcium supplementation for nutritional risk groups (elderly, housebound, veiled women, dark-skinned individuals).

Go to an emergency department immediately for: suspected open fracture (visible bone or deep wound near a fracture); severe deformity, shortening, or rotation of a limb after injury; inability to bear weight on a lower limb after trauma; severe pain with a tense, tight swelling in a limb (possible compartment syndrome — requires emergency fasciotomy); loss of sensation, severe tingling, or weakness distal to an injury site; suspected hip, femoral shaft, or spinal fracture; and fracture with absent distal pulse. Seek urgent medical review for: any fracture in a child involving a growth plate; a fracture occurring with very minor trauma in an adult (possible pathological fracture requiring investigation); and rib fractures in the elderly, which risk pneumothorax and pneumonia and frequently require hospital admission. Stress fractures (gradually worsening localised bone pain with exercise, improving with rest) require orthopaedic review and should not be pushed through without imaging confirmation.