Basics Of Fractures
Definition
A fracture is a partial or complete disruption in the continuity of a bone1. Fractures range from simple cracks (incomplete breaks) to complete breaks with multiple fragments (comminuted fractures) and may be classified as:
Closed (simple): skin intact.
Open (compound): broken bone communicates with the environment via a skin wound1.
Epidemiology
Malaysia
Self-reported bone fracture prevalence among Malaysian adults is 6.63% (n=1,019/15,378), with higher odds in males (adjusted odds ratio [aOR] 2.12; 95% CI: 1.69–2.65), those with prior injury (aOR 5.01; 95% CI: 3.10–6.32), and obesity (aOR 1.46; 95% CI: 1.13–1.89)2.
Hip fractures in Malaysia occur at an estimated rate of <6,000 annually, projected to rise to ~21,000 by 2040—the largest increase among AFOS member states—reflecting rapid population ageing3.
In patients aged ≥50 years, the incidence of hip fracture was 90 per 100,000, with highest rates in those 70–79 years (41.4%), a female:male ratio of 2:1, and ethnic distribution of Chinese (44.5%), Malay (40%), and Indian (13.9%)4.
Global
Worldwide, hip fracture incidence ranges from 95.1 to 315.9 per 100,000 among those aged ≥50 years; annual numbers are projected to nearly double by 2050 to >4 million cases, with substantial geographic variation in treatment and mortality5.
Pathophysiology
Fractures result from forces exceeding bone strength. Bone homeostasis follows Wolff’s law—remodeling in response to mechanical strain—via coupled osteoblastic (formation) and osteoclastic (resorption) activity6.
High-energy fractures (e.g., motor vehicle collisions) produce comminution and soft-tissue injury.
Low-energy (fragility) fractures occur with minimal trauma when bone is weakened by osteoporosis or malignancy7.
Stress fractures arise from repetitive loading exceeding the reparative capacity, common in runners and military recruits7.
Classification
AO/OTA alphanumeric system provides a uniform framework for long-bone fractures8:
Localization: bone (1 = humerus; 2 = radius/ulna; 3 = femur; 4 = tibia/fibula) and segment (1 = proximal; 2 = diaphyseal; 3 = distal).
Type: based on articular involvement—
A = extra-articular
B = partial articular
C = complete articular
Group/Subgroup: morphology (e.g., A1 spiral; A2 oblique; A3 transverse).
This classification guides severity assessment and management planning8.
Clinical Features
Patients typically present with acute pain, inability to bear weight or use the limb, swelling, deformity, and occasionally crepitus. Open fractures show skin breach and exposed bone.
Investigations
Bedside
Neurovascular assessment (pulses, capillary refill, sensation, motor function).
Wound evaluation in open injuries (prophylactic antibiotics within 3 hours).
Imaging
First-line: Plain radiographs (at least two orthogonal views)4.
Occult fractures: CT or MRI when radiographs are normal but clinical suspicion remains (e.g., occult hip fracture)4.
Monitoring
Serial radiographs to assess alignment and healing progress.
Rationales and management plans are detailed in dedicated sections on fracture management.
