70 TYPES OF FRACTURES

# 71: TYPES OF FRACTURES

A fracture is a break in the structural continuity of bone. The MRCS Part A doesn't reward you for parroting definitions — it rewards you for matching mechanism to pattern, recognising named fractures, classifying open injuries, and predicting which patients will fail to heal. Get those four right and almost every fracture SBA becomes manageable.

Describing a fracture

When you describe any fracture, examiners expect a consistent vocabulary:

- ➡ Open vs closed — is the skin breached? Open (compound) means the fracture haematoma communicates with the outside world — antibiotics within 1 hour, tetanus cover, debridement.

- ➡ Site — diaphyseal, metaphyseal, epiphyseal, intra-articular.

- ➡ Pattern — transverse, oblique, spiral, comminuted, segmental, greenstick, impacted, avulsion.

- ➡ Displacement — translation of the distal fragment described in millimetres or percentage.

- ➡ Angulation — direction of the apex (e.g. apex volar).

- ➡ Rotation — best assessed clinically (compare to the opposite limb).

- ➡ Shortening — overlap of fragments.

A clean answer is "displaced, dorsally angulated, transverse fracture of the distal radius" — the structure tells the examiner you know what you're looking at.

Mechanism dictates pattern

This is the single most testable concept in the topic.

Mechanism	Pattern
Direct blow (e.g. car bumper to femur)	Transverse
Pathological / metastatic deposit	Transverse (weak cortex fails under minimal load)
Twisting / torsion	Spiral
Compression + angulation	Oblique
High-energy axial load	Comminuted (≥3 fragments)
Two transverse fractures isolating a middle segment	Segmental
Child with pliable cortex bending on one side	Greenstick (incomplete)
Child with longitudinal compression	Buckle / torus
Tendon/ligament pulling off a bone fragment	Avulsion

👩‍⚕️ A "pathological" fracture is always transverse in MRCS questions — the cortex is so weakened by tumour, Paget's, or osteoporosis that it snaps cleanly across.

Pathological fractures

A pathological fracture occurs through abnormal bone. The bone fails under loads that wouldn't break a healthy skeleton — turning a door handle, catching a bus, a dog tugging the lead. Common causes:

- Metastases — breast, lung, thyroid, kidney, prostate (mnemonic: BLT-KP). Breast and lung are by far the commonest.

- Multiple myeloma — classic "punched-out" lytic lesions.

- Primary bone tumours — osteosarcoma, Ewing's, chondrosarcoma.

- Metabolic — osteoporosis, osteomalacia, Paget's, renal osteodystrophy.

- Benign lesions — simple bone cyst, fibrous dysplasia.

Prophylactic fixation is considered when Mirels' score ≥ 9 (site, pain, lesion type, size).

Stress fractures

Repetitive submaximal loading causes microfractures that outpace remodelling. Classic in military recruits, runners and dancers. The second metatarsal (march fracture) and tibia are the favourites. Plain films are often normal for 2–3 weeks; MRI or bone scan picks them up earlier. Treatment is rest and activity modification.

Open fractures — Gustilo-Anderson classification

Open fractures are graded by wound size, soft tissue damage, contamination and vascular injury. Learn this table cold — it appears in MRCS regularly.

Grade	Wound	Soft tissue	Contamination	Notes
I	< 1 cm	Minimal	Clean	Low energy, inside-out
II	1–10 cm	Moderate	Moderate	No extensive flaps/avulsion
IIIA	> 10 cm	Extensive	Heavy	Adequate soft tissue cover possible
IIIB	> 10 cm	Extensive	Heavy	Periosteal stripping; needs flap cover
IIIC	Any	Any	Any	Arterial injury requiring repair

👩‍⚕️ The single fact most often tested: IIIC = vascular injury, regardless of wound size. A small puncture with a transected popliteal artery is IIIC.

Management of any open fracture: IV antibiotics within 1 hour (co-amoxiclav or cefuroxime ± gentamicin per BOAST), tetanus prophylaxis, photograph the wound, saline-soaked dressing, splint, urgent senior review, theatre for debridement within 12–24 hours.

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Salter-Harris classification (paediatric physeal injuries)

In children, the physis (growth plate) is the weakest link — ligaments are stronger than the cartilaginous plate, so forces that would sprain an adult ankle fracture a child's physis. Salter-Harris grades these injuries by the fracture line's relationship to the physis.

Mnemonic: SALTR

- I — Slipped — through the physis only (Straight across).

- II — Above — through the physis and metaphysis (commonest, ~75%).

- III — Lower — through the physis and epiphysis (intra-articular).

- IV — Through everything — metaphysis, physis and epiphysis.

- V — Ruined / cRush — compression of the physis (worst prognosis, often missed on initial X-ray).

👩‍⚕️ Higher grade = higher risk of growth arrest. Types III, IV and V threaten the joint surface or the physis itself.

Fracture healing — the four stages

Secondary (callus-mediated) healing is what MRCS tests. It occurs with relative stability (cast, IM nail, bridging plate).

1. Haematoma formation (0–48 h) — bleeding from torn periosteal and medullary vessels forms a clot; cytokines (TNF-α, IL-1, IL-6) recruit inflammatory cells.

2. Fibrocartilaginous (soft) callus (2 days – 2 weeks) — fibroblasts and chondroblasts lay down a cartilaginous bridge; the fracture becomes "sticky" but mechanically weak.

3. Bony (hard) callus (2 – 6 weeks) — endochondral ossification converts cartilage to woven bone; clinical union typically at 4–6 weeks for an uncomplicated long bone.

4. Remodelling (months – years) — woven bone is replaced by lamellar bone along Wolff's law (bone remodels along lines of stress).

Primary (direct) healing occurs only with rigid fixation and anatomical reduction (e.g. lag screw + compression plate). No callus forms — osteoclasts cut cones cross the gap and lay down lamellar bone directly. Slower than callus healing and intolerant of any motion.

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Factors that impair fracture healing

Memorise these — they generate easy SBA marks.

Patient factors

- Smoking (nicotine → vasoconstriction, impaired osteoblast function)

- Diabetes mellitus

- Increasing age

- Malnutrition, vitamin D deficiency

- Steroids, chemotherapy, bisphosphonates (long-term)

- NSAIDs — inhibit prostaglandin-mediated osteoblast activity

- Peripheral vascular disease

Fracture factors

- Open fracture / infection

- Comminution and bone loss

- Poor blood supply (scaphoid waist, femoral head, talus, lateral 1/3 clavicle)

- Soft tissue interposition

- Distraction at fracture site

Treatment factors

- Inadequate immobilisation / excessive motion

- Inadequate reduction

- Premature weight-bearing

👩‍⚕️ Delayed union = healing slower than expected. Non-union = healing failed (atrophic = poor biology; hypertrophic = good biology, bad mechanics — "elephant's foot" on X-ray). Malunion = healed in poor alignment.

Early complications

Fat embolism syndrome — classically 24–72 hours after a long bone fracture (especially femur) or intramedullary nailing. Marrow fat enters venous circulation and lodges in the pulmonary capillaries. The triad is respiratory distress, cerebral dysfunction, petechial rash (axilla, chest, conjunctivae). Diagnosis is clinical (Gurd's criteria); treatment is supportive.

Compartment syndrome — rising pressure within a fascial compartment exceeds capillary perfusion pressure, causing ischaemia. Classic in tibial shaft and forearm fractures. The dominant symptom is pain out of proportion to injury, worsened by passive stretch of the compartment muscles. The 5 Ps (pain, pallor, paraesthesia, paralysis, pulselessness) are late and unreliable — pulses are usually preserved until the limb is doomed. Diagnosis: clinical, or compartment pressure within 30 mmHg of diastolic. Treatment: urgent fasciotomy, release all dressings/casts, no limb elevation (drops perfusion further).

Named fractures (high-yield)

These are pure pattern recognition — examiners love them.

Name	Description	Mechanism
Colles'	Distal radius, dorsally angulated ("dinner fork") ± ulnar styloid	FOOSH, older osteoporotic woman
Smith's	Distal radius, volarly angulated ("reverse Colles")	Fall onto flexed wrist
Bennett's	Intra-articular fracture-dislocation of base of 1st metacarpal	Axial blow on flexed thumb (punch)
Rolando's	Comminuted intra-articular base of 1st MC (Bennett's nastier cousin)	Higher energy
Boxer's	Neck of 5th metacarpal	Punch with closed fist
Scaphoid	Waist of scaphoid; tender anatomical snuffbox	FOOSH; risk of AVN of proximal pole
Galeazzi	Fracture of radial shaft + dislocation of distal radio-ulnar joint	Fall onto pronated arm
Monteggia	Fracture of proximal ulna + dislocation of radial head	Direct blow / FOOSH
Pott's	Bimalleolar ankle fracture	Forced eversion
Maisonneuve	Spiral fracture of proximal fibula + medial malleolus / deltoid ligament injury	External rotation; always palpate the proximal fibula in ankle injuries
Jones'	Fracture at base of 5th metatarsal (metaphyseal-diaphyseal junction)	Inversion; poor blood supply, non-union risk
Hangman's	Bilateral pars interarticularis fracture of C2	Hyperextension (judicial hanging, RTC)
Jefferson	Burst fracture of C1 (atlas)	Axial load (diving into shallow water)
Chance	Horizontal fracture through vertebral body and posterior elements	Flexion-distraction (lap seatbelt); associated intra-abdominal injury

👩‍⚕️ Mnemonics: GRaezzi → Radius; MUnteggia → Ulna. Dinner fork = Dorsal = Colles. Smith = Soft side (volar).

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Test yourself

A 10-year-old fell on his outstretched hand. He had minimal pain and swelling at the site of injury. What type of fracture occurred?

• ((Greenstick::☑️ Pliable paediatric cortex bends and fractures on one side only — minimal deformity.))
• ((Transverse::Pattern of direct blow or pathological fracture, not paediatric FOOSH.))
• ((Spiral::Requires a twisting/torsional mechanism.))
• ((Comminuted::Implies high-energy trauma with ≥3 fragments.))

👩‍⚕️ Greenstick and buckle (torus) fractures are unique to children — adult bone is too brittle to bend.

A 12-year-old boy fell on his hand while playing in the garden, resulting in minimal deformity. What is the expected type of fracture?

• ((Greenstick::☑️ Incomplete fracture through pliable cortex; minimal deformity is the giveaway.))
• ((Spiral::Twisting force needed — not described here.))
• ((Oblique::Compression plus angulation; usually obvious deformity.))
• ((Complete transverse::A complete fracture in a child would produce more deformity than described.))

A 16-year-old was hit by a car on the left thigh with a direct impact. What is the likely fracture pattern?

• ((Transverse::☑️ Direct blow perpendicular to a long bone produces a transverse line.))
• ((Spiral::Requires rotational injury, not direct impact.))
• ((Oblique::Compression with angulation — not a pure direct blow.))
• ((Greenstick::Paediatric pattern; a 16-year-old has near-adult cortical bone.))

A woman with metastatic breast cancer suffers a humeral injury while catching a bus. What is the most likely type of fracture?

• ((Transverse::☑️ Pathological fractures snap cleanly across cortex weakened by tumour.))
• ((Spiral::Needs significant twisting force, not minor traction.))
• ((Comminuted::Requires high-energy trauma; pathological bone usually fails simply.))
• ((Oblique::Compression-angulation pattern, not seen with minimal load on diseased bone.))

👩‍⚕️ Minimal trauma + known malignancy = think pathological fracture. Breast and lung are the commonest sources of bony mets.

A 70-year-old with multiple bony metastases fractures her humerus when her dog pulls the lead. Which pattern is most likely?

• ((Transverse::☑️ Cortex weakened by lytic lesion fails cleanly across under minimal load.))
• ((Spiral::Requires significant torsional force.))
• ((Comminuted::High-energy mechanism; not consistent with minor traction.))
• ((Oblique::Compression-angulation injury, not this mechanism.))

A 35-year-old footballer twists his ankle and breaks both tibia and fibula 2 cm above the joint. What pattern will the X-ray show?

• ((Spiral::☑️ Torsional/twisting mechanism produces a corkscrew-shaped fracture line.))
• ((Transverse::Direct-blow pattern, not twisting.))
• ((Oblique::Compression and angulation, not pure rotation.))
• ((Comminuted::High-energy axial load producing multiple fragments.))

A construction worker drops a steel beam on his shin. The X-ray shows a tibial fracture with > 10 cm wound, periosteal stripping but intact dorsalis pedis. Which Gustilo grade?

• ((IIIB::☑️ Large wound + extensive soft tissue loss + periosteal stripping; needs plastic surgery flap cover.))
• ((IIIA::Large wound but soft tissue cover still adequate without a flap.))
• ((IIIC::Reserved for fractures with arterial injury requiring repair.))
• ((II::Wound 1–10 cm with moderate soft tissue damage only.))

👩‍⚕️ The IIIA/IIIB split is about soft tissue cover — can the orthopod close it, or do you need plastics?

A motorcyclist has an open tibial fracture with a 2 cm wound and an absent posterior tibial pulse requiring vascular repair. Gustilo grade?

• ((IIIC::☑️ Any open fracture with arterial injury needing repair is IIIC, irrespective of wound size.))
• ((I::Wound size alone (< 1 cm) is irrelevant when the artery is cut.))
• ((II::Moderate wound without vascular injury.))
• ((IIIA::Large wound, adequate cover, intact vasculature.))

A 12-year-old falls off a trampoline. X-ray shows a fracture line through the metaphysis and physis of the distal radius. Salter-Harris type?

• ((Type II::☑️ Fracture through physis + metaphysis — commonest paediatric physeal injury (~75%).))
• ((Type I::Through the physis only, no bony involvement.))
• ((Type III::Through physis + epiphysis (intra-articular).))
• ((Type IV::Through metaphysis, physis AND epiphysis.))

👩‍⚕️ SALTR — Slipped, Above, Lower, Through, Ruined. Type V (crush) carries the worst growth-arrest risk.

A 25-year-old has an intramedullary nail for a femoral shaft fracture. 48 hours later he becomes confused, hypoxic and develops a petechial rash. Most likely diagnosis?

• ((Fat embolism syndrome::☑️ Classic triad — respiratory, neurological, petechial — 24–72 h after long bone fracture or IM nailing.))
• ((Pulmonary embolism::Usually presents with pleuritic pain and tachycardia; petechiae are not a feature.))
• ((Compartment syndrome::Localised pain and tense compartment, not systemic hypoxia and confusion.))
• ((Sepsis::Possible but does not cause the petechial rash of fat embolism.))

Six hours after a closed tibial shaft fracture, a 30-year-old has severe pain in the calf, worse on passive ankle dorsiflexion. Pulses are present. Next step?

• ((Urgent fasciotomy::☑️ Pain out of proportion + pain on passive stretch = compartment syndrome until proven otherwise; pulses are preserved until late.))
• ((Elevate the limb::Drops perfusion pressure and worsens ischaemia — contraindicated.))
• ((Repeat X-ray::Will not change management; clinical diagnosis demands theatre.))
• ((Reassure and analgesia::Delay risks irreversible muscle necrosis (Volkmann's contracture).))

👩‍⚕️ Compartment syndrome is a clinical diagnosis. Waiting for pulselessness means waiting too long.

A 60-year-old woman falls onto an outstretched hand and has a "dinner fork" deformity of the wrist. Which fracture?

• ((Colles' fracture::☑️ Distal radius with dorsal angulation — classic post-menopausal FOOSH.))
• ((Smith's fracture::Volar angulation (reverse Colles'), from a fall onto a flexed wrist.))
• ((Galeazzi fracture::Radial shaft fracture + distal radio-ulnar joint dislocation, not distal radius alone.))
• ((Bennett's fracture::Intra-articular fracture at base of the thumb metacarpal.))

A boxer punches a wall and fractures the neck of his 5th metacarpal. Eponymous name?

• ((Boxer's fracture::☑️ Neck of 5th metacarpal from a clenched-fist impact.))
• ((Bennett's fracture::Base of 1st metacarpal — thumb, not little finger.))
• ((Rolando's fracture::Comminuted intra-articular base of 1st metacarpal.))
• ((Smith's fracture::Volarly angulated distal radius — wrist, not hand.))

A patient twists his ankle. X-ray of the ankle is normal but he is tender over the proximal fibula. Which fracture must you exclude?

• ((Maisonneuve fracture::☑️ Spiral proximal fibula fracture + medial-side ankle injury — always palpate the whole fibula.))
• ((Jones' fracture::Base of 5th metatarsal — foot, not fibula.))
• ((Pott's fracture::Bimalleolar ankle fracture, visible on ankle films.))
• ((Galeazzi fracture::Forearm injury, irrelevant to ankle trauma.))

👩‍⚕️ A normal ankle X-ray with medial-side pain doesn't exclude a fracture — get a full-length tib/fib film.

A passenger restrained by a lap-belt only is in a high-speed RTC. He has a horizontal fracture through the L2 vertebral body and posterior elements. Eponymous name and key association?

• ((Chance fracture::☑️ Flexion-distraction injury from lap belts; ~50% have intra-abdominal injury (hollow viscus, pancreas).))
• ((Jefferson fracture::Burst fracture of C1 from axial loading.))
• ((Hangman's fracture::Bilateral C2 pars fracture from hyperextension.))
• ((Wedge compression fracture::Anterior column only; posterior elements intact.))

A young man dives head-first into a shallow pool. CT shows a burst fracture of C1. Eponym?

• ((Jefferson fracture::☑️ Axial load splits the atlas ring; usually neurologically intact unless transverse ligament ruptured.))
• ((Hangman's fracture::C2 pars fracture from hyperextension, not axial load.))
• ((Chance fracture::Thoracolumbar flexion-distraction injury.))
• ((Odontoid peg fracture::Fracture of the dens of C2, not a C1 burst.))

Revision summary

- Mechanism → pattern: direct blow / pathological = transverse; twisting = spiral; compression + angulation = oblique; high energy = comminuted; child + bend = greenstick.

- Pathological fracture: minimal trauma + abnormal bone (mets — BLT-KP, myeloma, Paget's, osteoporosis); fixation if Mirels' ≥ 9.

- Gustilo-Anderson: I < 1 cm clean; II 1–10 cm moderate; IIIA adequate cover; IIIB needs flap; IIIC = arterial injury, any wound size. Antibiotics within 1 hour.

- Salter-Harris (SALTR): I Slipped, II Above (commonest), III Lower, IV Through, V cRush (worst).

- Healing: haematoma → soft callus → hard callus → remodelling; clinical union ~4–6 weeks. Primary healing needs rigid fixation, no callus.

- Impairs healing: smoking, NSAIDs, diabetes, age, steroids, infection, motion, poor blood supply (scaphoid, talus, femoral head).

- Fat embolism: 24–72 h post long-bone fracture; respiratory + cerebral + petechial.

- Compartment syndrome: pain disproportionate, worse on passive stretch; pulses preserved late; urgent fasciotomy, no elevation.

- Named fractures: Colles dorsal / Smith volar / Bennett 1st MC / Boxer's 5th MC / Scaphoid (AVN) / Galeazzi → Radius / Monteggia → Ulna / Pott's bimalleolar / Maisonneuve proximal fibula / Jones' 5th MT / Hangman's C2 pars / Jefferson C1 burst / Chance lap-belt + abdo injury.