What is a Fracture?
Fracture descriptions and classifications

"Give it to me straight doc-is it broken or is it just fractured?" Patients often ask this question when they are told they have a fractured bone because they consider a break and a fracture two different injuries. Many people think a break means broken, requiring surgical treatment and a long recovery period, and a fracture needs only a cast or brace. However, the two terms mean the same thing. Actually, the general appearance of the fracture and the involved portion of the bone determines the necessary treatment.

Orthopaedists use uniform fracture descriptions and classifications to help explain to patients the appropriate treatment and the expected outcome of the treatment. The first consideration in fracture description is the age of the patient. Fractures in children require special attention because a child's bones are still growing and changing. An adult fracture is classified based on its location, direction, alignment, articular involvement (involving most of the joint rather than the shaft), and whether it is open or closed. Fracture description is further divided into the location of the break, that is the portion of the bone involved-proximal, middle, or distal. The direction of the fracture is described as transverse (fracture line is straight across the bone), spiral (fracture line spirals down the bone), oblique (slanted fracture line), comminuted (more than two fragments), or segmental (several large fractures in the same bone). Alignment describes whether the bone is angulated or straight. Finally, an open fracture means that bone fragments have broken through the skin causing an open wound, and a closed fracture means that there is no opening in the skin.

Children's fractures differ in classification and treatment from adult fractures because children have areas of cartilage called the physis, or growth plate (Fig. 2). Growth plates, located near each end of the body's long bones, determine the future length and shape of a mature bone. During adolescence, the growth plate's cartilage grows and matures into hard bone, therefore, the structure of the growth plate must be preserved so normal growth can occur. Unfortunately, the growth plate is the weakest area in children's bones. Of long bone fractures in children, 30% involve the growth plate-almost half of which are at the wrist.1

Growth plate injuries occur more often in boys than in girls, possibly because the growth plates remain open longer in boys and are exposed to more trauma through strenuous activity.2 Most of these fractures, called epiphyseal fractures, occur in boys between the ages of 12 and 15 years and in girls between the ages of 9 and 12 years. The most common classification of children's fractures are the six classifications described by Salter and Harris3 (Fig. 3). The first type is the simplest and least likely to cause disruption of normal growth. As the classification number increases, the more complex the fracture. For example, numbers 5 and 6 are the most complex because they result from a crush or avulsion (tearing away) injury, and are more likely to cause a growth plate injury.

There are many factors to consider in fracture description and classification. However, the most important aspect a patient should remember is that a break and a fracture are the same injury, and it always requires medical attention.

William D. Terrell, MD
Auburn, Alabama

References:
1. Mann DC. Distribution of Physeal and Nonphyseal Fractures of Long Bones in Children Aged 0-16 Years. Journal of Pediatric Orthopedics. 1990;10:713.
2. Caule T. Physeal Injuries. In: Green NE, Swiontkowski MF, Eds. Skeletal Trauma in Children. Vol. 3. 2nd ed. Philadelphia, PA:WB Saunders Co;1998:16.
3. Salter RB, Harris WR. Injuries Involving the Epiphyseal Plate. Journal of Bone and Joint Surgery. 1963;45A:587.