A broken bone or a fracture (Latin fractura , "break", from Latin frangere "break"), also outdated leg fracture , is an interruption of the continuity of a bone with the formation of two or more fragments ( fragments ) with or without displacement ( dislocation ). In medical documentation, a fracture is often abbreviated with the sign # ( double cross ).
Broken bones are usually the result of direct or indirect violence in the context of an accident , a fall, blow or impact. A bone can also fracture partially or completely as a result of acute repeated overloading. Such a fatigue break is z. B. a marching fracture of a metatarsal bone, also called a stress fracture.
If a fracture occurs even though the force applied is insufficient to break a healthy bone, a pathological fracture has occurred, also known as a spontaneous fracture . Then there is another disease, such as generalized or local osteoporosis , a bone metastasis or a benign or malignant bone tumor , which reduce the resistance of the bone.
In many cases, a broken bone is associated with other injuries. On the one hand, the bone fracture itself can injure neighboring vessels and nerves, or a bone fracture that extends into a joint can be accompanied by a dislocation of the joint . The accident can also trigger multiple injuries with injuries to internal organs, traumatic brain injuries or larger wounds. In the case of particularly severe multiple injuries, there is a multiple trauma .
Compartment syndrome is a delayed complication, especially with fractures of the lower leg ; with open fractures there is a significant risk of bacterial infection, which can lead to sepsis or osteomyelitis .
During the clinical examination, a distinction is made between safe and unsafe fracture signs, whereby the absence of certain signs of fracture is not a sure sign of the non-existence of a fracture. If a fracture is also not visible in the X-ray, it is called an occult fracture .
The certain signs of fracture should be obtained without manipulation; a special test should be avoided in order to reduce pain and to prevent further accompanying injuries. However, in the event of an obvious malalignment, immediate reduction should be carried out while pulling into the natural position, also to prevent further injuries. Safe fracture signs are:
- Axis misalignments (e.g. foot pointing in the wrong direction)
- Bone protruding from the wound
- Step formation in the bone contour
- Bone gaps (diastases)
- abnormal mobility
- Crunching of the break point ( crepitation ).
From a systematic point of view, a fracture gap in the X-ray image or in the fracture ultrasound is actually not a reliable clinical sign of a fracture, as it is not evident from the clinical examination, but from further imaging.
All clinical signs that can occur even without a fracture are therefore not conclusive and are considered uncertain signs of fracture. In particular, these are the five signs of inflammation :
- Pain (dolor)
- Swelling (tumor)
- Blush (rubor)
- Warmth (calor)
- limited mobility (functio laesa)
Another unsafe sign of a fracture is a bruise ( hematoma ).
The exclusion of peripheral nerve and vascular injuries is also very important during the examination , which is done by testing the sensitivity and muscle strength distal to the fracture and by feeling the peripheral pulses . Since injuries to vessels and nerves can still occur until the supply is stable and a compartment syndrome occurs only after a delay, these tests must be repeated regularly.
Classification of fractures
A distinction is made between fractures according to several criteria:
- Number of fragments
- Completeness (complete / incomplete)
- AO classification
- open and closed fractures
According to the number of fragments
- One-fragment fractures (only one fracture gap)
- Piece fractures (up to three additional fragments)
- Comminuted fractures (more than three additional fragments)
According to the localization
- Shaft fractures ( diaphyseal fractures)
- Fractures near the joint ( metaphyseal fractures)
- Joint fractures (fractures involving the joint surface and dislocation fractures )
A systematic classification of long bones fractures was developed in 1958 by the Working Group for Osteosynthesis Questions (AO). This AO classification is now generally used as the basis for describing fractures in everyday clinical practice as well as in scientific publications.
The AO classification primarily consists of four numbers or letters describing a broken bone. Other codes describe the associated skin, soft tissue and vascular nervous damage. The first digit describes the area of the body affected (e.g. 2 = forearm, i.e. radius or ulna ). The next number describes the more precise localization and differentiates between fractures close to the body / proximal fractures (1), shaft fractures (2, diaphyseal) and distal fractures (3). This is followed by letters A – C, which indicates the complexity of the fracture and differs in the description depending on whether the fracture is located in the shaft or joint area. The following number divides again into simple, multiple and complex fractions.
- 22A1 - a simple fracture in the middle of the forearm, in medical terms an ulnar shaft fracture
- 23C3 - a severe fracture of the distal forearm with joint involvement, whereby both the ulna and the radius are splintered several times ( comminuted fracture of the wrist)
- 32A3 - a fracture in the middle of the femur with additional axis misalignment
Open or closed fracture
Furthermore, a distinction is made between open fractures and closed fractures. Open fractions are usually more complicated than closed ones; there is an additional risk of infection due to the injury to the skin .
According to Tscherne and Oestern, the severity of the soft tissue injury is documented in both cases as follows:
- Grade 0: No or insignificant soft tissue injury, indirect force, simple fracture form
- Grade I: Superficial abrasion or bruising ( contusion ) due to fragment pressure from the inside, simple to moderate fracture form
- Grade II: Deep, dirty skin abrasion, contusion due to direct violence, threatened compartment syndrome , moderate to severe form of fracture
- Grade III: extensive skin contusion or destruction of the muscles, subcutaneous décollement , manifest compartment syndrome , damage to a main vessel
- Grade I: impalement of the skin, insignificant soiling (contamination), simple fracture form.
- Grade II: Severing the skin, circumscribed skin and soft tissue contusion, moderate contamination , all forms of fracture
- Grade III: extensive soft tissue destruction, frequent vascular and nerve injuries, severe wound contamination, extensive bone destruction
- Grade IV: “Subtotal” (i.e. incomplete) amputation injury with less than 1/4 of the soft tissue sheath intact and extensive damage to nerves and blood vessels.
In the Anglo-American language area, the classification according to Gustilo and Anderson is mostly used for open fractures, which is very similar to the above classification, but instead of grade IV, grade III is given in grade IIIA-C (IIIa: bones covered by periosteum; IIIb : Bones deperiated and heavy contamination with germs; IIIc: with vascular damage) subdivided.
Overview of the fracture forms
Impression / expression fracture
Fractures, mostly related to skull bones. In an impression fracture, parts of the bone are pressed inwards by external action. (See also trepanation ). In an expression fracture, pressure / acceleration of the brain pushes thin parts of the bone (base of the skull, eye socket) outwards.
Simple, transverse fracture. Often caused by direct force acting on the fixed extremity, e.g. B. by a blood tackle in football.
Like transverse fracture, but oblique fracture line at different angles. The course of the accident is also similar, only with an oblique force.
Is caused by kinking the extremity on an edge or direct impact. There may be a transverse break, angled break or a piece break (angled break with a flexible wedge). One example is the so-called parrying fracture , in which the direct force of force leads to an isolated fracture of the ulna in the shaft area.
Spiral or torsion fracture
Spiral fracture line over a shorter or longer distance. Occurs through indirect violence (twisting of the fixed extremity). Often in alpine skiing .
Occurs on the bony skull. Fracture from the action of blunt force. Star-shaped fracture lines, often with indented fragments.
Forcible fracture on the longitudinal axis of a bone. Accident often leads to falls from a great height.
The avulsion fracture is also called a "bony avulsion". The underlying mechanism is a sudden increase in tension in a tendon or ligament at the bony attachment. Due to the higher tensile strength of the tendons and ligaments - especially in younger people - compared to the bone, a cortical shell or even an entire bone fragment is torn off.
- Outer ankle fracture ( Weber -A)
- Tear off the base of the metatarsal vein (through the tendon of the peroneus brevis muscle)
- Tearing of the ulnar epicondyle at elbow dislocation
A special form in the child is the tearing of the tibial tuberosity through the patellar tendon, because the cartilaginous system is a continuation of the tibial epiphysis, so that the joint surface can also be involved.
According to JA Ogden, there is a subdivision into
- I: Tear off the distal part of the tuberosity
- II: Demolition of the tuberosity and / or parts of the epiphysis
- III: Extension of the injury through the epiphysis into the joint space.
Another special form is the fracture of the eminentia intercondylaris , which usually occurs in childhood. The division is based on Meyers and McKeever :
- Type I: undislocated
- Type II: partial
- Type III: completely dislocated
Also called chisel fracture: When a joint is compressed, part of the bone is sheared off as if with a chisel blow. Occurs on the head of the spoke and the head of the tibia.
(Synonyms: fatigue fracture , stress fracture ) Fracture due to constant cyclical loading of a bone; also called "march fracture" on the metatarsal bone.
Diagnosis is difficult because such a fracture only becomes visible on the X-ray after a periosteal reaction after a few weeks. Magnetic resonance tomography is suitable for diagnosing and distinguishing from other diseases.
Pathological fractures are broken bones without "adequate trauma" d. H. without major external forces on bones that are pathologically weakened by tumor settlements (metastases) or by tumor-like changes (e.g. bone cysts). Tumors that often metastasize to the bones are e.g. B. breast cancer (breast cancer) and prostate cancer. The pathological fracture must be differentiated from stress fractures and insufficiency fractures.
In the case of insufficiency fractures, the bone breaks as a result of structural weakness under normal or slightly increased stress. Usually there is a reduced calcium content of the bones ( osteoporosis ). Examples are compression or sintering fractures of the vertebral bodies with loss of height and deformities of the spine up to the so-called "widow's hump" or spontaneous fractures of the sacrum.
In stress fractures, on the other hand, fractures occur in normally stable bones due to repetitive, chronic overload, e.g. B. in the context of excessive physical activity.
- Injuries to nerves, vessels, joints and other neighboring structures
- Compartment syndrome
- Volume depletion shock due to external or internal bleeding (if bleeding from a large tubular bone, 500 to 3000 ml of blood can escape)
- Infection (post-traumatic osteomyelitis )
- Pseudarthrosis (formation of a wrong joint due to the bone ends not growing together)
- Sudeck dystrophy ( complex regional pain syndrome )
- Fat embolism
- Bridges callus
- ischemic contracture
Fracture healing and treatment
Essentially, the decision must be made whether conservative fracture treatment z. B. can be done by a plaster restraint, or whether surgical treatment must be carried out. Conservative treatment also includes the closed reduction of a deformity under anesthesia with a subsequent cast. The surgical procedure usually involves open repositioning of the bone fragments and their subsequent fixation by means of osteosynthesis ("ORIF" - open reduction and internal fixation ). In general, surgical correction is recommended in the case of multiple fragments, fractures that cannot be fully repositioned, persistent instabilities, fractures that extend into the joint. An absolute indication for surgery is the presence of arterial occlusion, nerve injury or a compartment syndrome. In the case of open fractures, too, an operation is usually carried out in order to be able to perform debridement and because safe stabilization reduces the risk of later infection. In the case of large defects, several repetitive interventions for restoration and debridement are often required.
In addition to the type of fracture, the procedure essentially depends on which bone is affected, the accompanying illnesses and injuries of the patient, and the available resources.
The broken bone is neither set nor straightened by the first aider, it should not cause unnecessary pain. The victim is to be moved or transported as little as possible. It leaves the patient's posture to take, the Bruchextremität superimposed peacefully and notes if needed the break area on the adjacent joints also a Sam Splint or suitable soft cushioning material (eg. As rolled blankets, Dreiecktücher from the first aid kit , clothing, pillows o. Ä.) Calm: The broken body part is carefully padded with the material and otherwise left in the position found. If the break is open, the wound should be covered with aseptic dressings or a bandage . Further manipulations of the break point are to be left to the rescue service . This should be alerted after the emergency measures have been taken.
When performing first aid measures, the current position of the injured person must be taken into account. He will adopt a relieving posture on his own initiative, the aim here is to support and relieve the patient. Storage should be safe and adequately protected from hypothermia or overheating. Since there is a risk of shock when large bones or multiple bones fracture, as well as any soft tissue or internal injuries , the injured person should not be left alone. When storing, make sure that there is enough space for appropriate measures in the event of a shock.
Swelling is common in closed fractures. To prevent this, the area of the bone fracture should be covered with cold compresses or something similar. be carefully cooled, making sure that the aid that is used for cooling is not too cold, as this could lead to hypothermia. The cooling can reduce the bleeding into the tissue and the pain of the person affected - both also risk factors for a life-threatening shock - can be alleviated.
Bleeding wounds caused by open fractures are treated like other bleeds - sterile wound dressing but not a pressure bandage ! If necessary, protruding bone parts are to be treated like foreign bodies, i.e. covered gently and sterile.
After the quiet position, the rest of the measures to take care of the patient are continued, which is important
- Monitoring for shock
- Check the vital parameters (breathing, pulse) at regular intervals
- Care of bleeding wounds
- Maintaining body heat ( see hypothermia ), for example with the help of a rescue blanket or items of clothing
- DMS control (blood circulation, motor skills, sensory functions)
- If necessary, stabilization of body and life functions ( intensive care medicine , resuscitation )
According to new study data, hip fractures are apparently more common than previously assumed: an estimated 141 per 100,000 population suffer a hip fracture in Germany every year . These fractures can therefore be described as a frequent occurrence. Icks et al. analyzed all discharge cases nationwide with a hip fracture diagnosis in 2004 based on hospital diagnosis statistics. 116,281 patients with at least one hospital stay per year due to hip fracture were calculated. That corresponds to an incidence of 141 per 100,000 inhabitants. So far, the incidence has been estimated at 122 per 100,000 inhabitants based on data from a large nationwide health insurance company. Apart from vertebral fractures, hip fractures are a particularly feared complication in osteoporosis patients . Because an estimated 30 percent of those affected die within a year. And: every third person with a hip fracture becomes permanently disabled.
- Martin Porr: fractures. In: Alfred Czarnetzki (Hrsg.): Mute witnesses of their suffering. Diseases and Treatment Before the Medical Revolution. Attempto Verlag, Tübingen 1996, ISBN 3-89308-258-1 , pp. 159-182.
- Christoph Drösser: Are bones stronger after a fracture than before? - no . In: The time . Edition 18/2011, April 29, 2011.
- Alois Walde : Latin etymological dictionary. 3rd edition, obtained from Johann Baptist Hofmann , 3 volumes. Heidelberg 1938-1965, Volume 1, p. 541.
- Karl Heinz Austermann: Fractures of the facial skull . In: N. Schwenzer (Ed.): Tooth-Oral-Kieferheilkunde: Textbook for education and training . 3rd, updated and extended Edition. tape 2 , Special Surgery, ed. by Norbert Schwenzer and Michael Ehrenfeld. With contributions by Karl Heinz Austermann…. Thieme, Stuttgart, New York 2002, ISBN 3-13-593503-5 , pp. 283 f .
- Maurice E. Müller: The Comprehensive Classification of Fractures of Long Bones in: ME Müller u. a. (Ed.): Manual of Internal Fixation . 3. Edition. S. 118 ff. Springer-Verlag, Berlin / Heidelberg / New York / Tokyo 1991, ISBN 3-540-52523-8 .
- A. Rueter, O. Trentz and M. Wagner (ed.): Traumatology , published by Urban and Schwarzenberg, Munich - Vienna - Baltimore 1995, ISBN 3-541-17201-0 , page 69.
- Marianne Abele-Horn: Antimicrobial Therapy. Decision support for the treatment and prophylaxis of infectious diseases. With the collaboration of Werner Heinz, Hartwig Klinker, Johann Schurz and August Stich, 2nd, revised and expanded edition. Peter Wiehl, Marburg 2009, ISBN 978-3-927219-14-4 , p. 166.
- B. Geldhauser, S. Guckenhan, R. Heudorfer: Chop injuries and trepanations. In: Alfred Czarnetzki (Hrsg.): Mute witnesses of their suffering. Diseases and Treatment Before the Medical Revolution. Attempto Verlag, Tübingen 1996, ISBN 3-89308-258-1 , pp. 183-205.
- J. AJ. A. Ogden, RB Tross, MJ Murphy: Fractures of the tibial tuberosity in adolescents. In: The Journal of bone and joint surgery. American volume. Volume 62, Number 2, March 1980, pp. 205-215, PMID 7358751 . Ogden, RB Tross, MJ Murphy: Fractures of the tibial tuberosity in adolescents. In: The Journal of bone and joint surgery. American volume. Vol. 62, No. 2, March 1980, pp. 205-215, . PMID 7358751 . .
- WR Shelton, ST Canale, Fractures of the tibia through the proximal tibial epiphyseal cartilage. In: The Journal of Bone and Joint Surgery 61, 1979, pp. 167-173.
- MH Meyers, FM McKeever: Fracture of the intercondylar eminence of the tibia. In: The Journal of bone and joint surgery. American volume. Vol. 52, No. 8, December 1970, pp. 1677-1684, PMID 5483091 . .
- Rainer Fritz Lick , Heinrich Schläfer: Accident rescue. Medicine and technology . Schattauer, Stuttgart / New York 1973, ISBN 978-3-7945-0326-1 ; 2nd, revised and expanded edition, ibid 1985, ISBN 3-7945-0626-X , p. 174.
- DMW 133, 2008, 125
- Hip fractures more often than expected. In: Doctors newspaper online. Springer Medizin Verlag, Berlin, July 16, 2008, accessed on May 22, 2019 .