2. Fractures and Dislocations

Learning Objectives

• Define fracture and dislocation and distinguish between the two
• Classify fractures by skin integrity, fracture pattern, and mechanism of injury
• Identify common causes of fractures including trauma, osteoporosis, and overuse
• Describe the diagnostic approach including physical examination and imaging
• Outline treatment options from conservative management to surgical fixation
• Explain the principles of rehabilitation and return to function after fracture or dislocation
• Recognize red flags that indicate a complex or high-risk fracture requiring urgent management

Quick Answer

A fracture is a partial or complete break in a bone caused by force that exceeds the bone's structural limits. A dislocation is displacement of a bone from its normal joint position. Fractures are classified by skin integrity (open vs. closed), pattern (comminuted, greenstick, stress), and cause (traumatic, pathological, overuse). Diagnosis relies on history, physical exam, and imaging — primarily X-ray. Treatment ranges from RICE and immobilization for minor injuries to surgical fixation for complex fractures, followed by rehabilitation to restore strength and function.

What Are Fractures?

Definition

A fracture is a partial or complete break in one or more bones. It occurs when the bone is subjected to more stress than it can withstand, causing it to crack or shatter.

Types of Fractures

There are several types of fractures, including:

• Closed fractures: The skin remains intact
• Open fractures: The skin is broken, exposing the bone — high infection risk
• Comminuted fractures: The bone breaks into multiple fragments
• Greenstick fractures: Partial breaks, often seen in children whose bones are more flexible
• Stress fractures: Small cracks in bones caused by repetitive force, common in athletes and military recruits

Common Causes of Fractures

Fractures can occur due to various reasons:

• Trauma (falls, accidents, high-energy collisions)
• Osteoporosis (low bone density increases fragility)
• Cancer or bone metastases (pathological fractures)
• Genetic disorders affecting bone strength
• Overuse or repetitive strain

What Are Dislocations?

Definition

A dislocation occurs when a bone is forced out of its normal position in a joint. This can happen suddenly due to trauma or, in some joints, gradually over time.

Types of Dislocations

Dislocations can be classified as:

• Acute dislocations: Occur suddenly due to trauma
• Chronic dislocations: Develop gradually over time, often related to joint laxity or repeated minor injury
• Recurring dislocations: Repeatedly occur after an initial injury — common at the shoulder in young athletes

Common Causes of Dislocations

Dislocations can result from:

• Trauma (falls, sports injuries — shoulder and knee most commonly affected)
• Overuse or repetitive strain
• Congenital joint abnormalities (e.g., developmental dysplasia of the hip)
• Medical conditions affecting bone density or ligamentous laxity

Diagnosis Methods

Diagnosing fractures and dislocations typically involves:

1. Physical examination — swelling, deformity, tenderness, neurovascular assessment
2. Imaging tests — X-rays are first-line; CT scans for complex fractures; MRI for soft tissue or occult fractures
3. Bone scans — particularly useful for stress fractures when X-rays are normal

Always assess neurovascular status (pulse, sensation, motor function) distal to the injury before and after reduction or fixation.

Treatment Options

The treatment approach depends on the severity and type of fracture or dislocation:

• RICE: Rest, Ice, Compression, Elevation — for minor injuries in the acute phase
• Immobilization: Using casts or splints for less severe, stable fractures
• Closed reduction: Manipulation of displaced fracture or dislocation under analgesia or sedation without surgery
• Open reduction and internal fixation (ORIF): Surgery with plates, screws, or intramedullary nails for unstable or displaced fractures
• External fixation: Temporary stabilization for open fractures or polytrauma patients
• Joint relocation: Prompt reduction of dislocations — delay increases risk of avascular necrosis

Rehabilitation Process

Rehabilitation is crucial for proper healing and recovery:

• Phase 1: Pain management and protection of the healing structure
• Phase 2: Range-of-motion exercises to prevent stiffness
• Phase 3: Strengthening exercises
• Phase 4: Functional training and return-to-sport or return-to-work protocols

Early mobilization (within safe limits) is preferred over prolonged immobilization to prevent muscle atrophy, joint stiffness, and deep vein thrombosis.

Prevention Strategies

To reduce the risk of fractures and dislocations:

• Maintain strong bones through calcium-rich diet, vitamin D, and weight-bearing exercise
• Wear protective gear during high-risk activities (helmets, pads, wrist guards)
• Improve balance and coordination, especially in elderly patients (fall prevention programs)
• Manage underlying medical conditions (osteoporosis treatment, cancer monitoring)
• Avoid smoking and excessive alcohol — both impair bone density and fracture healing

Key Terms

Term	Definition	Related Concept
Closed fracture	Fracture where skin remains intact	Open fracture, infection risk
Open fracture	Fracture where bone communicates with external environment	Gustilo classification, surgical emergency
Comminuted fracture	Bone broken into three or more fragments	High-energy trauma, ORIF
Greenstick fracture	Incomplete fracture; one cortex buckles rather than breaks	Pediatric bone flexibility
Stress fracture	Fatigue fracture from repetitive loading	Athletes, shin splints, MRI diagnosis
Dislocation	Complete displacement of articular surfaces	Shoulder, hip, knee joint
Subluxation	Partial or incomplete dislocation	Shoulder instability, patellar tracking
ORIF	Open reduction and internal fixation — surgical stabilization with hardware	Plates, screws, intramedullary nails
Avascular necrosis	Death of bone tissue due to disrupted blood supply	Hip dislocation, femoral neck fracture
Malunion	Fracture heals in an incorrect position	Angular or rotational deformity
Nonunion	Failure of a fracture to heal within expected timeframe	Tibia shaft, scaphoid fractures
RICE	Rest, Ice, Compression, Elevation — acute injury first aid	Minor fractures, sprains

Common Mistakes

Misconception: All fractures require surgery. Why it's wrong: The majority of fractures — including many closed, non-displaced fractures — heal successfully with conservative management using casting or splinting. Surgery is reserved for displaced, unstable, open, or intra-articular fractures that cannot be managed conservatively. Correct understanding: Treatment is individualized based on fracture type, displacement, location, and patient factors. Many fractures heal well without surgical intervention.

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Misconception: A normal X-ray rules out a fracture. Why it's wrong: Stress fractures and some occult fractures (e.g., scaphoid fractures, femoral neck fractures in osteoporotic patients) may not be visible on initial X-rays. Bone scans and MRI are more sensitive for these injuries. Correct understanding: If clinical suspicion is high and X-ray is negative, further imaging (MRI or CT) should be performed. "X-ray negative" does not mean "fracture negative."

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Misconception: A dislocated joint should be reduced immediately without imaging. Why it's wrong: Pre-reduction imaging is essential to identify associated fractures (e.g., fracture-dislocations of the hip or shoulder) that could be worsened by blind reduction attempts. Correct understanding: Obtain X-rays before reduction in most cases unless there is an obvious neurovascular emergency; post-reduction films confirm successful relocation and detect associated injuries.

Comparison and Connections

Feature	Fracture	Dislocation
Definition	Break in bone continuity	Bone displaced from joint
Primary imaging	X-ray (AP and lateral views)	X-ray to confirm and identify associated fractures
Immediate risk	Blood loss, neurovascular injury, open wound	Neurovascular compromise, avascular necrosis
First-line treatment	RICE + immobilization; ORIF if unstable	Prompt closed reduction under sedation
Healing timeframe	Weeks to months depending on bone and severity	Joint stability restored over weeks; recurrence risk remains
Common example	Colles fracture (distal radius), tibial shaft fracture	Anterior shoulder dislocation, hip dislocation

Practice Questions

Recall

1. List five types of fractures and briefly describe each. Guidance: Closed, open, comminuted, greenstick, stress — define each by skin integrity, pattern, and mechanism.

2. What is the difference between a dislocation and a subluxation? Guidance: Dislocation = complete loss of articular contact; subluxation = partial loss. Both require prompt assessment and imaging.

Understanding

3. Why are open fractures considered orthopedic emergencies? Guidance: Bone is exposed to the external environment, creating high risk for osteomyelitis. Require urgent surgical debridement, irrigation, and prophylactic antibiotics.

4. Explain why greenstick fractures occur predominantly in children rather than adults. Guidance: Children's bones are more elastic and less fully ossified — they bend rather than break completely, causing an incomplete fracture on the tension side.

Application

5. A 28-year-old marathon runner presents with gradually worsening shin pain over 3 weeks. X-ray is normal. What is the most likely diagnosis and how should it be investigated? Guidance: Stress fracture of the tibia. MRI is the most sensitive modality; bone scan is an alternative. X-ray may become positive later showing periosteal reaction.

6. An elderly woman falls on an outstretched hand and presents with a "dinner fork" deformity of the wrist. What is the likely fracture and its management? Guidance: Colles fracture (distal radius fracture with dorsal displacement). Closed reduction and casting if stable; ORIF if displaced or unstable.

Analysis

7. Compare conservative versus surgical management of fractures, considering indications, risks, and expected outcomes. Guidance: Conservative = casting/splinting for closed, non-displaced, stable fractures; surgical = ORIF for displaced, unstable, intra-articular, or open fractures. Weigh infection risk, hardware failure, and anesthesia risks against non-union and malunion risks.

8. A 22-year-old basketball player sustains a recurrent anterior shoulder dislocation (third episode this season). What factors would guide the decision between conservative and surgical management? Guidance: Age, activity level, number of recurrences, degree of instability, presence of bony Bankart lesion on imaging all factor into the decision for surgical stabilization (Bankart repair).

FAQ

How long does a fracture take to heal? Healing time varies considerably depending on the bone involved, the patient's age, and the type of fracture. Simple closed fractures of small bones (fingers, toes) may heal in 3 to 4 weeks, while major long bone fractures (tibia, femur) typically take 3 to 6 months. Children generally heal faster than adults. Factors that slow healing include smoking, poor nutrition, osteoporosis, corticosteroid use, and inadequate immobilization.

What is a pathological fracture and who is at risk? A pathological fracture occurs through bone that has been weakened by an underlying disease rather than by excessive trauma. Common causes include osteoporosis, bone metastases (from breast, prostate, lung, or kidney cancer), multiple myeloma, and Paget's disease. Any patient who fractures a bone with minimal trauma should be investigated for an underlying cause, especially if they are elderly or have a known malignancy.

When is surgery truly necessary for a fracture? Surgery is generally indicated when: the fracture is open (contaminated); reduction cannot be maintained in a cast; the fracture involves a joint surface (intra-articular); critical structures like blood vessels or nerves are compromised; or the patient is elderly with a hip fracture (early surgery improves outcomes and reduces mortality). The decision always involves weighing surgical risk against the consequences of conservative management.

What is the RICE protocol and when should it be used? RICE stands for Rest, Ice, Compression, and Elevation. It is the first-line approach for acute musculoskeletal injuries in the first 24 to 72 hours, including minor fractures, sprains, and dislocations after reduction. Ice reduces swelling and pain; compression limits edema; elevation reduces fluid accumulation. RICE does not replace proper medical evaluation — any suspected fracture should be assessed with imaging.

Why is avascular necrosis a feared complication of hip dislocation? The femoral head receives most of its blood supply through vessels that run along the femoral neck and through the hip joint capsule. When the hip dislocates, these vessels are stretched or torn, cutting off blood supply to the femoral head. Without blood flow, bone tissue dies — leading to collapse of the femoral head, severe arthritis, and ultimately the need for hip replacement. This is why hip dislocations must be reduced within 6 hours whenever possible.

Quick Revision

• A fracture is a partial or complete bone break; a dislocation is bone displaced from its joint
• Open fractures break through the skin — high infection risk, treated as emergencies
• Greenstick fractures are incomplete fractures unique to children due to bone flexibility
• Stress fractures from repetitive loading may not appear on initial X-ray — use MRI or bone scan
• Always assess neurovascular status distal to a fracture or dislocation
• RICE (Rest, Ice, Compression, Elevation) is first-line for acute injuries
• ORIF is used for displaced, unstable, intra-articular, or open fractures
• Dislocations require prompt reduction — delay increases risk of avascular necrosis
• Pre-reduction imaging is essential to rule out associated fractures
• Rehabilitation phases: pain control → range of motion → strengthening → functional return
• Complications of fractures: non-union, malunion, avascular necrosis, compartment syndrome, infection
• Pathological fractures occur through diseased bone — always investigate the underlying cause

Related Topics

Prerequisites: Bone anatomy and physiology, musculoskeletal anatomy, basic trauma assessment, X-ray interpretation

Related Topics: Musculoskeletal Disorders (osteoporosis), Pediatric Orthopedics (Salter-Harris fractures), Sports Medicine (stress fractures, acute injuries), Orthopedic Surgery Techniques (ORIF, external fixation)

Next Topics: Musculoskeletal Disorders, Pediatric Orthopedics, Orthopedic Surgery Techniques