A fracture is a violation of the integrity of bone, which occurs as a result of the action of physical (mechanical) factors or pathological processes. The mechanism of fracture may be direct or indirect.

With the direct mechanism of fracture, the damage zone and the point of application of force coincide, respectively, with the indirect mechanism, the place of damage and the point of application of traumatic force do not coincide (for example, when the force is applied to a retracted arm, the point of application of force is hand, it can lead to a fracture of the surgical neck of the humerus).

Fracture classification

1. By origin, all fractures are divided into two groups: traumatic and pathological.
   • Traumatic fractures occur in an intact bone when the force of mechanical action is so high that it exceeds the strength of the bone.
   • Pathological fractures occur when much less force is applied (sometimes when turning in a bed, supporting with a table, etc.), which is associated with a previous bone lesion (pathological malignant tumor metastases, tuberculosis, osteomyelitis, syphilitic gum, decreased bone strength in hyperparathyroidism etc.).

2. According to the presence of damage to the skin, fractures are divided into:

• Open – in the presence of damage to the skin and mucous membranes, in which the wound communicates with the fracture zone.
• Closed – fractures that occurred without disturbing skin and mucous membranes.

3. According to the direction of fracture line: transverse, oblique, longitudinal, comminuted, twisted, avulsion, compression and separation fractures are distinguished.

Fracture diagnosis

Clinical picture

Clinical examination of a patient with a fracture is carried out according to the general principles of examination of patients with acute injury.

When collecting anamnesis, it is necessary to clarify the state of function after damage (whether the patient could move a limb, walk, lean on his leg, etc.). In some cases, at the time of injury, the victim hears crunching of the broken bone, which, with an adequate condition of the patient, can be considered an essentially reliable sign of a fracture.

An objective examination determines symptoms characteristic of a fracture, which are divided into two groups: absolute and relative.

 

1. A) Absolute symptoms

Symptoms are called absolute, the detection of at least one of which reliably indicates the presence of a fracture.

There are three absolute symptoms of a fracture:

• Characteristic deformation.
• Pathological mobility.
• Bone crepitus.

But there are times when the patient does not have these signs, this happens, for example, with an avulsion fracture, fracture of flat bones.

 

Characteristic deformation. Characteristic deformation is understood as a change in the configuration of the limb (bayonet deformation, change in the axis of the limb – fracture of arm bones, fracture of leg bones; rotation in the fracture region – fracture of the radius with displacement), as well as those cases where displaced bone fragments are visible to the naked eye.

 

Pathological mobility – the presence of movement in atypical places. It is defined as follows: the doctor fixes the proximal part of the limb with his hand and exposes the distal to a moderate, non-painful, rocking motion. If the doctor feels at least minimal independent mobility of the peripheral part of the limb concerning a central symptom, it is considered positive (very often in a bone fracture with shift).

 

Bone crepitus – the sound of crunching or corresponding touch sensations arising from the friction of bone fragments against each other. This symptom may occur when the patient tries to move the limb, dresses up, applies or removes the transport splint.

 

1. B) Relative fracture symptoms

In the absence of absolute symptoms, the diagnosis can be made by identifying a set of relative symptoms – signs characteristic not only of a fracture but also of other diseases.

1) Pain syndrome, of course, is present in patients with a fracture. Pain is intense, intensifies with movement. It is especially diagnostically important to identify sharp local pain in fracture or soreness with axial load.

2) Hematoma in the region of fracture, in some types, can reach large sizes: fracture of the humerus – 600 ml, fracture of the radius – 500 ml.

3) The shortening of the limb indicates a fracture of leg bone with a shift, its forced position. It should be remembered that this symptom can also be with dislocation.

4) Disruption of function in the fracture is usually very significant: the patient cannot stand with support on the limb, move the limb up off the surface of the bed (a symptom of “sticking heel” in case of a hip fracture), the limb cannot maintain its weight (fracture of the tibia), etc. This symptom is very important to diagnose spinal fracture.

If in a patient the majority of relative symptoms are determined, this allows the physician to clinically diagnose a bone fracture.

The main instrumental method for diagnosing fractures is X-ray examination.

Arm fracture with displacement

Correctly performed x-ray allows to determine the nature of the damage (fracture, dislocation), to determine the line of fracture, the presence and nature of displacement.

In complex cases, radiography can be supplemented by computed tomography and nuclear magnetic resonance imaging. This is especially true for the diagnosis of damage to the vertebrae and intervertebral discs.

Other additional research methods can clarify the severity of the general condition and diagnose damage to blood vessels and internal organs. Laboratory studies (complete blood count, urinalysis, biochemical blood test) allow to assess the severity of blood loss, presence of an inflammatory reaction, to identify signs of damage of internal organs (hematuria, increased transaminases, plasma creatinine, etc.).

Dopplerography, angiography, MRI angiography are used to diagnose vascular damage.