AKT · Musculoskeletal/Fractures, trauma & soft tissue

Fractures & pathological fractures

Break in bone cortex — traumatic, fragility (osteoporotic), or pathological (through abnormal bone)

Overview

A breach of bone continuity. Most follow trauma; a fragility fracture follows low-energy trauma (osteoporosis); a pathological fracture occurs through abnormal bone (metastasis, myeloma, primary tumour, Paget's) with minimal or no trauma. Management follows reduce–hold–rehabilitate, with attention to the soft tissues and the underlying bone health or pathology.

Recognise

Pain, swelling, deformity, loss of function; localised tenderness, abnormal movement/crepitus
X-ray confirms: describe site, pattern (transverse/oblique/spiral/comminuted), displacement, angulation, intra-articular involvement, open vs closed
Pathological fracture: minimal trauma, prior bone pain, known cancer, lytic lesion on X-ray

Red flags

Open fracture (wound communicating with bone) → IV antibiotics, tetanus, photograph + cover, urgent orthoplastics
Neurovascular compromise distal to the fracture, or compartment syndrome → emergency
Pathological fracture → investigate the underlying cause (metastasis/myeloma)

Differentials & how to tell them apart

Soft-tissue injury / sprainno cortical break on imaging; ligamentous

Pathological fracturethrough abnormal bone — minimal trauma, lytic lesion

Stress fracturerepetitive loading; may be occult on initial X-ray, seen on MRI

Scaphoid fracture (FOOSH)anatomical-snuffbox tenderness after a fall on the outstretched hand; OFTEN OCCULT on the initial X-ray → immobilise and re-image/MRI; proximal-pole avascular necrosis risk

Comminuted hip (neck-of-femur) fracture (X-ray)
R. R. Memon et al. / CC BY 4.0 — Wikimedia Commons

Investigations

X-ray (two views, joint above and below); CT for complex/intra-articular fractures; MRI/bone scan if pathological/occult (e.g. scaphoid, hip); assess neurovascular status; bloods + myeloma/metastasis work-up for pathological fractures; DEXA for fragility fractures.

Management

Reduce + immobilise + analgesia; open fracture → antibiotics + debridement; treat the underlying bone

1Assess neurovascular status and the soft tissues; confirm and characterise on X-ray. Provide analgesia, reduce and immobilise. Open fractures → IV antibiotics, tetanus and urgent orthoplastic management.Gate: Neurovascular compromise or compartment syndrome distal to the fracture is an emergency; a pathological fracture (minimal trauma/lytic lesion) needs investigation of the underlying cause before fixation.
2Definitive fixation for unstable/displaced/intra-articular fractures, then rehabilitation; treat the underlying bone (osteoporosis after a fragility fracture, oncology for pathological fractures).

Analgesia + reduce, immobilise (cast/splint), elevate — the reduce–hold principle; check neurovascular status before and after

Open fracture: IV antibiotics + tetanus prophylaxis + urgent debridement — orthoplastic management; do not delay antibiotics

Definitive fixation (ORIF/IM nail/external fixation) as indicated — for unstable/displaced/intra-articular fractures; rehabilitation follows

Treat the underlying bone disease — osteoporosis therapy after a fragility fracture; oncological management of pathological fractures

Key points

Reduce–hold–rehabilitate. Always check and document neurovascular status and the soft tissues. Open fracture → antibiotics + tetanus + debridement. A fragility fracture mandates osteoporosis treatment; a pathological fracture (minimal trauma + lytic lesion) mandates a malignancy/myeloma work-up.

Monitor & prognosis

Healing on serial X-ray (union), neurovascular status, complications, bone-health treatment.

Most heal well; complications (non-union, malunion, AVN, infection) and underlying pathology modify outcome.

Source: BOAST/NICE NG38; cross-ref osteoporosis & bone tumours