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General principles of fractures

Last updated: August 3, 2021

Summarytoggle arrow icon

A fracture is a partial or complete interruption in the continuity of bone. The most common cause is trauma, followed by diseases (e.g., osteoporosis) that result in weakened bone structure. The latter results in pathologic fractures, which are fractures that would not usually occur if the bone structure was not weakened. Open fractures, in which the bone is exposed due to severe soft tissue injury, are associated with a significant risk of infection and poor wound healing. Fracture management can be conservative (e.g., cast or splint) or surgical, and generally involves anatomic reduction, fixation, and/or immobilization. Complications include acute nerve and vascular injury and compartment syndrome, as well as long-term complications such as avascular necrosis and nonunion.


Fracture classification

Based on the following characteristics:

Common fractures in children

See “Pediatric fractures” for details.

Common fractures in adults

Pathologic fracture

Open fracture [2]

  • Definition
    • A fracture in which bone fragments break through the skin
    • Associated with significant soft tissue injury and an increased risk of complications (infection, poor healing)
  • Etiology: secondary to trauma

Other fractures

  • Pain, redness, and swelling at the site of injury
  • Deformity and axis deviation
  • Bone fragments penetrating the skin
  • Palpable step-off or gap
  • Bone crepitus
  • Concomitant soft tissue injuries
  • Neurovascular compromise below the site of injury

Clinical assessment


  • X-ray
    • Requirements
      • 2 joints (if limb fracture)
      • 2 times (prereduction and postreduction)
    • Radiographic signs of a fracture include a radiolucent fracture line and cortical disruption.
    • Describe fracture based on the anatomic location, alignment , angulation, and articular involvement (see “Classification” above for details)
    • X-ray imaging has a low sensitivity for detecting stress fractures.
  • CT/MRI (not routine): indicated in preoperative planning for complicated fractures, assessment of associated injuries, and inconclusive x-ray findings

General approach

Conservative fracture management

Surgical fracture management

  • Indications
  • Procedure: anatomic reduction of the fracture and subsequent fixation and immobilization
    • External fixation: immobilizing a fracture using pins or screws that are secured outside the skin
    • Internal fixation: immobilizing a fracture using implants (e.g., plates, screws, wires)
    • Open reduction and internal fixation: realignment of the ends of a fracture, and stabilization of the fracture using implants (e.g., plates, screws, wires)

Acute complications

Long-term complications

Nonunion [3]

Complications due to immobilization

We list the most important complications. The selection is not exhaustive.

  1. Open Fractures. Updated: June 1, 2011. Accessed: February 7, 2017.
  2. Wick JY. Spontaneous fracture: multiple causes. Consult Pharm. 2009; 24 (2): p.100-113. doi: 10.4140/TCP.n.2009.100 . | Open in Read by QxMD
  3. Stewart SK. Fracture Non-Union: A Review of Clinical Challenges and Future Research Needs.. Malaysian orthopaedic journal. 2019; 13 (2): p.1-10. doi: 10.5704/MOJ.1907.001 . | Open in Read by QxMD