An overview of bone injuries
A fracture is a break in the bone, which occurs commonly as a result of accidents, falls or other injuries. Except for trauma, fractures can also be caused by low bone density and osteoporosis, which weaken the bone [1, 2].
Broadly, we can classify fractures based on their type and characteristics.
By the nature of the break, we can classify fractures into:
- single - bone is broken in one place into two pieces;
- comminuted - bone is broken into three or more pieces, or crushed into small fragments.
By the nature of the injury, we can classify fractures into:
- compresion - the bone collapses under pressure;
- torque - the bone is twisted and breaks;
- bending - the limb is bent and the bone snaps;
- shear - where large bone structures such as the pelvis separate into multiple pieces along a straight line [3].
There are two additional types of fracture that do not fit in the above criteria:
- stress fractures - these occur as a result of repetitive force, such as in sports like running;
- deficiency fractures - these are a result of metabolic disorders affecting bone mineralisation, such as osteomalacia or osteoporosis [4].
On diagnostic imaging (which is almost always X-ray in the case of fractures), fractures can be classified based on the alignment of the bones into:
- non-displaced fracture - the bone breaks in the pieces which stay aligned normally;
- displaced fracture - the bones are out of their normal alignment;
- segmental fracture, where the bone is broken in two (or more) places, leaving a floating segment (or multiple) [2].
Treatment of fractures
Treatment of all fractures, regardless of the type and mechanism of injury, has one objective: stabilise the broken bone in its proper position and allow it to heal.
Most commonly, this is done with a cast or a splint. In some cases (usually more advanced injuries), traction may be used to stabilise the area. This involves a system of pulleys and weights fixed to a frame over the patient's bed, which stretch the muscle and tendons around the broken bone [5].
Prior to fixation, some fractures require a procedure known as reduction, where a doctor will push and pull on the limb to get the broken bone(s) back in their normal alignment.
For more complex fractures, surgery may be required. The exact surgical approach and procedure depends on the type, location and extent of the fracture, however, the goal is to reposition the broken bone into its normal alignment and fix the pieces together using hardware such as screws, rods or plates. This is known as internal fixation. There is also external fixation, which involves inserting pins or screws into the bone above and below the fracture, which are then connected to a frame positioned outside the patient's limb. This allows for manipulating the bone from the outside as the fracture heals [5].
Risks of untreated fracture
When a fracture is not treated, the patient is exposed to several risks. As with any other disease or injury, rapid therapeutic intervention is essential for good outcomes. It is therefore important to promptly visit a doctor after an injury, especially if you suspect that you have a broken bone.
The largest risks include:
- Persistent pain an impaired healing - the bone may not heal correctly without fixation by a doctor. This may cause pain in the long term.
- Impaired function of the limb - without fixation and reduction, the body may repair the fracture, however the bones may not be aligned properly. This may result in functional deficiencies such as limitation of movement.
- Development of osteoporosis or osteoarthritis - these are bone density and inflammatory conditions, which have the potential to cause many issues in the long term, including an increased risk of recurrent fractures [6], as well as pain and functional defects [7]. In fact, the risk of recurrent fractures has been determined to be as high as 41% with an untreated first fracture [6].
Fracture-related infections - a potentially fatal complication
One of the most dangerous complications of an untreated fracture, which may be life-threatening, are fracture-related infections (FRIs). Moreover, these infections can be difficult to diagnose and treat, leading to adverse health outcomes, which may include loss of limb function, amputation or death [8].
The most common pathogens associated with FRIs are Staphylococcus aureus, polymicrobial infections, and multi-drug-resistant organisms [8]. In a study conducted in Northeast China, Staphylococcus aureus was identified as the most common pathogen at all sites of infection [9]. In addition to Staphylococcus aureus, a study conducted in South East Asia found a large numebr of pathogens at the sited of FRIs, including Pseudomonas spp., Escherichia coli, Klebsiella spp., Acinetobacter spp., Enterobacter spp., and Proteus spp. [10]. What is worrying is the fact that a large number of these pathogens was resistant to multiple types of antibiotics, making treatment challenging.
While the data on mortality of FRIs are limited, it is clear that these infections can lead to adverse health outcomes. One such outcome is sepsis, a condition where the body's immune system over-reacts to an infection, damaging other organs in the process. The mortality of sepsis varies, however it is well-established that it is deadly. For severe sepsis, mortality rates range between 25% to 30%. The most extreme form of sepsis, can approach 50%. Additionally, patients that survive and are treated successfully may face long-term impairments, including cognitive and functional deficits.
Mortality of fractures in general
The data on mortality of untreated fractures is scarce as it is very difficult to collect. However, it is well established that untreated fractures are associated with infections, which can be fatal.
There are, however, data on mortality of fractures in general. For example, a patient study with hip fractures (HF), vertebral fractures (VF), and upper extremity fractures (UEF) concluded 2-year mortalities of 42.9%, 36.5%, and 34.6% respectively [11]. Another study reported that the 1-year mortality rates after fractures of the femur or pelvis, vertebrae, humerus, rib, or clavicle, and lower leg were 20-25%, 10%, 5-10%, and 3% respectively [12].
Summary
All fractures should be treated as soon as possible to minimise complications. If you think you may have a broken bone, it is important to visit a doctor immediately and get the potential fracture X-rayed and evaluated. Untreated fractures are associated with development of complications such as persistent pain, loss of function of the limb, or development of fracture-related infections, which can be fatal.