A fracture is described as a disruption in the continuity of all or part of the cortex of a bone.

If the cortex is broken through and through, the fracture is called complete. If only a part of the cortex is fractured, it is called incomplete. Incomplete fractures tend to occur in bones that are "softer" than normal such as those in children, or in adults with bone-softening diseases such as osteomalacia or Paget disease. Incomplete fractures in children are the greenstick fracture, which involves only one part of cortex, and the torus fracture (buckle fracture), which represents compression of the cortex .

Abrupt disruption of all or part of the cortex Acute changes in the smooth contour of a normal bone Fracture lines are black and linear Where fracture lines change their course, they tend to be sharply angulated Fracture fragments are jagged and not corticated

Sesamoids are bones that form in a tendon as it passes over a joint. Accessory ossicles are accessory epiphyseal or apophyseal ossification centers that do not fuse with the parent bone. Old, unhealed fracture fragments can sometimes mimic acute fractures .

Radiologic features

Unlike fractures, these small bones are corticated (i.e., there is a white line that completely surrounds the bony fragment) and their edges are usually smooth. In the case of sesamoids and accessory ossicles, they are usually bilaterally symmetrical so that a view of the opposite extremity will usually demonstrate the same bone in the same location. They also occur at anatomically predictable sites like thumb, the posterolateral aspect of the knee (fabella), and the great toe. Accessory ossicles are most common in the foot

In a dislocation, the bones that originally formed the two components of a joint are no longer in apposition to each other. In a subluxation, the bones that originally formed the two components of a joint are in partial contact with each other.

There is a common lexicon used in describing fractures to facilitate a reproducible description and to assure reliable and accurate communication. Fractures are usually described using four major parameters

The number of fragments The direction of the fracture line The relationship of the fragments to each other By communication of the fracture with the outside

atmosphere

If the fracture produces two fragments, it is called a simple fracture. If the fracture produces more than two fragments, it is called a comminuted fracture. Some comminuted fractures have special names. A segmental fracture is a comminuted fracture in which a portion of the shaft exists as an isolated fragment. A butterfly fragment is a comminuted fracture in which the central fragment has a triangular shape.

In a transverse fracture, the fracture line is perpendicular to the long axis of the bone caused by a force directed perpendicular to shaft. In a diagonal or oblique fracture, the fracture line is diagonal in orientation relative to the long axis of the bone caused by a force usually applied along the same direction as the long axis of the affected bone. With a spiral fracture, a twisting force or torque produces a fracture like those that might be caused by planting the foot in a hole while running usually unstable.

By convention, abnormalities of the position of bone fragments secondary to fractures describe the relationship of the distal fracture fragment relative to the proximal fragment. Based on the position the distal fragment would have normally assumed had the bone not been fractured. There are four major parameters most commonly used to describe the relationship of fracture fragments.

Displacement Angulation Shortening Rotation

Displacement describes the amount by which the distal fragment is offset, front to back and side to side, from the proximal fragment. Displacement is most often described either in terms of percent (the distal fragment is displaced by 50% of the width of the shaft) or by fractions (the distal fragment is displaced half the width of the shaft of the proximal fragment).

Angulation describes the angle between the distal and proximal fragments as a function of the degree to which the distal fragment is deviated from the position it would have assumed were it in its normal position. Angulation is described in degrees and by position (the distal fragment is angulated 15 anteriorly relative to the proximal fragment)

Shortening describes how much, if any, overlap there is of the ends of the fracture fragments, which translates into how much shorter the fractured bone is than it would be had it not been fractured. The term opposite from shortening is distraction, which refers to the distance the bone fragments are separated from each other. Shortening (overlap) or distraction (lengthening) is usually described by a number of centimeters (there are 2 cm of shortening of the fracture fragments).

Rotation is an unusual abnormality in fracture positioning almost always involving the long bones, such as the femur or humerus. Rotation describes the orientation of the joint at one end of the fractured bone relative to the orientation of the joint at the other end of the same bone. Normally, for example, when the hip joint is pointing forward, the knee joint is also pointing forward. If there is rotation about a fracture of the femoral shaft, the hip joint could be pointing forward while the knee joint is oriented in another direction. To appreciate rotation, both the joint above and the joint below a fracture must be included, preferably on the same radiograph.

A closed fracture is the more common type of fracture in which there is no communication between the fracture fragments and the outside atmosphere. In an open or compound fracture, there is communication between the fracture and the outside atmosphere, i.e., a fracture fragment penetrates the skin. Compound fractures have implications regarding the way in which they are treated in order to avoid the complication of osteomyelitis.

Soft tissue swelling -Frequently accompanies a fracture but does not necessarily mean that a fracture is present Disappearance of normal fat stripes - The pronator quadratus fat stripe on the volar aspect of the wrist, for example, may be displaced with a fracture of the distal radius. Joint effusion - The positive posterior fat pad sign seen on the dorsal aspect of the distal humerus from a traumatic joint effusion is an example. Periosteal reaction - Sometimes the healing of a fracture will be the first manifestation that a fracture was present, especially with stress fractures of the foot.

Some fractures are more difficult to detect than others. Scaphoid fractures (common), Buckle fractures of the radius and ulna (common), Radial head fractures (common), Supracondylar fractures (common), Posterior dislocations of the shoulder (uncommon) Hip fractures (common).

Immediately following a fracture, there is hemorrhage into the fracture site. Over the next several weeks, osteoclasts act to remove the diseased bone. The fracture line may actually minimally widen at this time. Then, over the course of several more weeks, new bone (callus) begins to bridge the fracture gap. Internal endosteal healing is manifest by indistinctness of the fracture line leading to obliteration of the fracture line. External, periosteal healing is manifest by external callus formation eventually leading to bridging of the fracture site. Remodeling of bone begins at about 8 to 12 weeks as mechanical forces, in part, begin to adjust the bone to its original shape. In children, this occurs much more rapidly and usually leads to a bone that eventually appears normal. In adults, this process may take years and the healed fracture may never assume a completely normal shape.

FACTORS THAT AFFECT FRACTURE HEALING

Accelerate Fracture Healing Youth Early immobilization
Delay Fracture Healing

Old age Delayed immobilization

Adequate duration of immobilization Too short a duration of immobilization Good blood supply Poor blood supply Physical activity after adequate immobilization Steroids

Adequate mineralization

Osteoporosis, osteomalacia

Delayed union- fracture does not heal in the expected time for a fracture at that particular site (e.g., 6 to 8 weeks for a fracture of the shaft of the radius). Most cases of delayed union will eventually progress to complete healing with further immobilization. Malunion- healing of the fracture fragments occurs in a mechanically or cosmetically unacceptable position. Nonunion- fracture healing will never occur. It is characterized by smooth and sclerotic fracture margins with distraction of the fracture fragments. A pseudarthrosis, complete with a synovial lining, may form at the fracture site.