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

A fracture is a structural break in bone continuity — ranging from a hairline crack to complete cortical and medullary disruption — caused by acute trauma, repetitive stress loading (stress fracture), or pathological weakening of bone by disease (pathological fracture). Approximately 178 million new fractures occur globally each year, making them among the most common musculoskeletal presentations in emergency medicine and primary care. The global incidence is driven by high-energy trauma (road traffic accidents, falls from height, sporting injuries), fragility fractures in the growing elderly population with osteoporosis (approximately 8.9 million osteoporotic fractures worldwide annually), and stress fractures in military recruits and distance runners. Fractures are classified by skin integrity: closed (skin intact — majority) or open/compound (bone communicates with external environment through a wound — risk of contamination and osteomyelitis); by anatomical pattern: transverse, oblique, spiral (high-energy rotational mechanism), comminuted (three or more fragments), or greenstick (incomplete cortical break in paediatric bone); and by articular involvement: extra-articular or intra-articular (requiring anatomical reduction to prevent post-traumatic arthritis). Hip fractures in the elderly carry the highest mortality of all common fractures — 20–30% one-year mortality — representing one of the most significant orthopaedic public health challenges globally.

Traumatic fractures result from acute mechanical overload exceeding the strength and elasticity of bone. Common mechanisms include falls (the leading cause of fractures in all age groups — responsible for 90% of hip and wrist fractures in the elderly), motor vehicle and motorcycle accidents (high-energy mechanisms causing comminuted, complex fractures — femur, pelvis, spine), sporting injuries (contact sports — clavicle, finger, ankle; skiing — tibia; cycling — clavicle, wrist), direct blows, and crush injuries in industrial accidents. Stress fractures (fatigue fractures) result from repetitive cyclic loading applied to normal bone before the rate of adaptive bone remodelling can compensate for micro-damage accumulation — common in distance runners (metatarsals, tibia, navicular), military recruits during basic training (metatarsals, tibia — incidence 1–5% in new recruits), dancers (femoral neck, sesamoids), and jumping athletes; the female athlete triad (relative energy deficiency in sport — RED-S, low bone density, and menstrual dysfunction) markedly increases stress fracture risk. Pathological fractures occur through bone weakened by underlying disease, often with minimal or trivial trauma: osteoporosis (the most common systemic bone disease — reduced bone mineral density below the fracture threshold, present in 30% of women over 50; bisphosphonate therapy reduces fracture risk 40–60%); metastatic bone disease (lung, breast, prostate, kidney, thyroid primaries — causing lytic or mixed lesions in the axial skeleton, femur, and humerus); primary bone tumours (osteosarcoma, Ewing's sarcoma — pathological fracture through tumour is a surgical emergency); Paget's disease of bone (focal bone remodelling causing abnormal, enlarged, structurally weak bone particularly in the pelvis, femur, and skull); osteomalacia (vitamin D deficiency causing defective bone mineralisation); osteogenesis imperfecta (brittle bone disease — type I collagen mutations).

The clinical presentation of a fracture depends on the bone involved, mechanism, and severity. In acute traumatic fractures: immediate severe pain localised precisely to the fracture site (periosteal stretching and haematoma formation), exquisitely point tender on direct palpation; swelling (soft tissue oedema and haematoma accumulation — appears within minutes to hours); bruising (ecchymosis — may extend distally from the fracture with haematoma tracking along fascial planes over 24–72 hours); deformity — visible angulation, shortening, or rotation of the injured limb; crepitus (grating sensation from bone fragment ends — should not be deliberately elicited as this causes additional pain and soft tissue injury); inability to bear weight through the affected limb (lower limb fractures) or use the limb functionally (upper limb fractures). Vascular compromise (a surgical emergency): pallor, pulselessness, and cold, mottled skin distal to the fracture (supracondylar humerus fractures — brachial artery injury in children; femoral shaft fractures — femoral artery; open tibial fractures — tibial artery) — requires immediate vascular surgery consultation. Neurological deficit: paraesthesia, hypoesthesia, or weakness distal to the fracture — sciatic nerve in posterior hip dislocation; radial nerve in humeral shaft fractures; median nerve in distal radius fractures. Open (compound) fractures: visible bone protruding through a skin wound or a wound in close proximity to a fracture — represent a surgical emergency requiring immediate washout and stabilisation to prevent deep infection (osteomyelitis) and non-union. Stress fractures present with a characteristic gradual onset of localised bone pain during activity, initially mild and relieved by rest, progressing to pain at rest and at night — distinguished from soft tissue injury by point tenderness directly over the bone.

Plain radiography (X-rays) in two orthogonal planes is the first-line investigation for all suspected fractures — it identifies most cortical fractures and assesses displacement, angulation, comminution, and articular involvement. Specific X-ray views are required for certain fractures — scaphoid views (ulnar deviation) for suspected scaphoid fracture; Mortise view for ankle; lateral decubitus for clavicle. CT (computed tomography): the investigation of choice for complex periarticular fractures (tibial plateau, calcaneum, acetabulum, pilon), spinal fractures (all suspected spinal injuries should have CT — sensitivity above 99% for bony injury), and pre-operative planning where 3D reconstruction guides surgical implant placement and approach. CT angiography is indicated when vascular injury is suspected based on clinical signs of ischaemia. MRI (magnetic resonance imaging): the gold standard for occult fractures not visible on plain X-ray (particularly hip fractures in elderly patients — MRI has near 100% sensitivity and should be obtained within 24 hours if X-ray is negative and clinical suspicion is high, as delayed hip fracture fixation significantly increases mortality); stress reactions and stress fractures (bone marrow oedema on STIR/fat-suppressed sequences — visible 24–48 hours before X-ray findings); soft tissue injuries to ligaments, tendons, and articular cartilage coexisting with periarticular fractures; bone contusion (trabecular microfractures from impaction injury without visible cortical break). DEXA (dual-energy X-ray absorptiometry) bone mineral density scanning: indicated for any patient over 50 with a low-energy fracture to diagnose osteoporosis and guide bisphosphonate therapy. Bone scintigraphy (technetium bone scan): demonstrates stress fractures as 'hot spots' of increased uptake from osteoblastic activity — now largely replaced by MRI in most centres.

Fracture management follows established principles: preserve life (haemorrhage control — femur fractures can cause up to 2L blood loss; open pelvic fractures up to 4L, requiring pelvic binder application, resuscitation, and pelvic embolisation); preserve limb (vascular and neurological injury must be identified and treated within the 'golden hour'); then restore anatomy and function. Conservative management: undisplaced or minimally displaced, stable fractures — plaster cast or backslap splint (fibreglass or plaster of Paris); duration and weight-bearing instructions are fracture-specific. Closed reduction (manipulation) under anaesthesia or sedation for displaced but reducible fractures — followed by immobilisation. Traction: used in femoral shaft fractures as temporary stabilisation before definitive fixation (Thomas splint with skin or skeletal traction for 48–72 hours pre-operatively). Open reduction and internal fixation (ORIF): the standard surgical approach for unstable, displaced, or intra-articular fractures — devices include cortical and cancellous screws, dynamic hip screw (DHS — for hip fractures), locking compression plates (LCP — allow angular stability for osteoporotic bone), intramedullary nails (IM nails — for diaphyseal fractures of tibia, femur, humerus — allow early weight-bearing by sharing load with bone), tension band wiring (patella, olecranon), and cannulated screws (scaphoid, femoral neck). External fixation: temporary stabilisation for open fractures and damage control orthopaedics in polytrauma — a frame of percutaneous pins and external bars maintains alignment while soft tissues recover before definitive fixation. Total hip arthroplasty (THA) or hemiarthroplasty: preferred over internal fixation for displaced femoral neck fractures in the elderly (lower re-operation rate and better functional outcomes). Rehabilitation: physiotherapy commences immediately post-operatively — early mobilisation prevents DVT, deconditioning, and promotes bone healing. Bone healing aids: vitamin D (800 IU/day) and calcium (1,200 mg/day) supplementation in elderly patients; teriparatide (PTH analogue) shown to accelerate fracture healing in osteoporotic patients.

Acute complications (within hours to days): Compartment syndrome — the most time-critical acute complication; occurs when pressure within an enclosed osseofascial compartment exceeds the capillary perfusion pressure (typically above 30 mmHg or within 30 mmHg of the diastolic blood pressure); caused by bleeding and oedema from crush injury, tibial shaft fracture, forearm fracture, and circumferential burns; the clinical '6 P's': pain out of proportion (the earliest and most sensitive sign — pain worsening despite adequate analgesia and pain on passive stretch of muscles in the compartment), pulselessness (late sign — irreversible muscle necrosis begins 6–8 hours after ischaemia even with palpable distal pulses), pallor, paraesthesia, paralysis, poikilothermia (cold limb); treatment is emergency fasciotomy — release of all compartment fasciae; delay beyond 6 hours causes irreversible Volkmann's ischaemic contracture (forearm) or claw toes (leg). Vascular injury: immediate arterial repair within 6 hours is required for brachial artery injury (supracondylar humerus fractures in children) and popliteal artery injury (posterior knee dislocation). Fat embolism syndrome (FES): emboli of fat droplets from fractured medullary cavity (especially femur) cause pulmonary infiltrates (ARDS), petechial rash (axillae, conjunctivae), and confusion — typically 24–72 hours post-injury; treatment is supportive. DVT and PE: immobilisation after fracture, especially lower limb — prophylactic LMWH (enoxaparin 40 mg/day or rivaroxaban) is standard for hip and tibial fractures. Delayed complications: malunion (healed in incorrect alignment causing deformity, limb length discrepancy, or altered joint mechanics); nonunion (failure to unite at 6 months — requires bone grafting, exchange nailing, or biologic agents such as BMP-2); avascular necrosis (AVN) particularly of the femoral head (hip fracture — 15–30% risk in displaced femoral neck fractures) and scaphoid (proximal pole — 30–40% after proximal third scaphoid fracture); post-traumatic arthritis (in intra-articular fractures).

Osteoporosis prevention is the foundation of fracture prevention in the elderly — the WHO FRAX tool calculates the 10-year probability of major osteoporotic fracture based on age, gender, BMI, risk factors, and BMD, guiding bisphosphonate therapy decisions. Bisphosphonates (alendronate 70 mg/week or risedronate 35 mg/week — oral; zoledronic acid 5 mg IV annually): reduce vertebral fracture risk by 60–70% and hip fracture risk by 40–50% in osteoporotic patients. Calcium (1,000–1,200 mg/day from diet and supplements) and vitamin D (800–1,000 IU/day) are essential adjuncts to bisphosphonate therapy. Denosumab (Prolia — anti-RANKL monoclonal antibody, 60 mg SC every 6 months): an alternative for those unable to take bisphosphonates; associated with rebound vertebral fracture risk if discontinued — must be transitioned to bisphosphonate. Falls prevention: home hazard modification (remove trip hazards — rugs, trailing cables; install handrails in bathrooms and stairways); exercise programmes targeting balance and lower limb strength (Otago exercise programme — reduces falls by 35% and fall-related injuries by 40% in over-65s; Tai Chi); review of fall-risk medications (benzodiazepines, sedating antihistamines, antihypertensives causing postural hypotension, antipsychotics); correction of visual impairment (cataract surgery reduces falls); foot care (proper footwear, podiatry for foot pain). Hip protectors: foam-padded garments reducing hip fracture severity — modest evidence for efficacy in care home residents. Stress fracture prevention in athletes: nutritional adequacy (caloric intake, calcium, vitamin D); training load monitoring (progressive weekly mileage increase below 10%); biomechanical assessment; addressing RED-S (energy deficiency) and menstrual dysfunction in female athletes.

Go to A&E immediately for: any suspected fracture following significant trauma — severe pain, swelling, bruising, deformity, or inability to bear weight or use a limb; any open (compound) fracture where bone is visible through skin (cover with a clean dressing, do not push bone back, call 999 or go directly to A&E); any suspected spinal fracture (neck or back pain with trauma — keep still, call 999, do not move the person without trained help); numbness, pins and needles, weakness, or poor circulation (cold, pale limb) below a fracture site — possible nerve or vascular injury requiring emergency surgery. Hip pain with inability to weight-bear after a fall in an elderly patient is a hip fracture until proven otherwise — call 999 and do not delay. For children, growth plate fractures may not be visible on initial X-ray; persistent point tenderness over a growth plate area after injury warrants orthopaedic review even if initial X-ray is normal. Stress fractures present gradually — if activity-related bone pain persists for more than 2-3 weeks and does not improve with rest, see your GP for imaging referral.