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Children in general are at greater risk because of their high activity levels. Children that have risk-prone behaviors are at even greater risk.
Over 2.5 million child abuse and neglect cases are reported every year, and thirty-five out of every hundred cases are physical abuse cases. Bone fractures are sometimes part of the physical abuse of children; knowing the symptoms of bone fractures in physical abuse and recognizing the actual risks in physical abuse will help forward the prevention of future abuse and injuries. Astoundingly, these abuse fractures, if not dealt with correctly, have a potential to lead to the death of the child.
Fracture patterns in abuse fractures that are very common with abuse are fractures in the growing part of a long bone (between the shaft and the separated part of the bone), fractures of the humeral shaft (long bone between the shoulder and elbow), ribs, scapula, outer end of the clavicle, and vertebra. Multiple fractures of varying age, bilateral fractures, and complex skull fractures are also linked to abuse. Fractures of varying ages occur in about thirteen percent of all cases.
Removable splints result in better outcomes than casting in children with torus fractures of the distal radius.
The greenstick fracture pattern occurs as a result of bending forces. Activities with a high risk of falling are risk factors. Non-accidental injury more commonly causes spiral (twisting) fractures but a blow on the forearm or shin could cause a green stick fracture. The fracture usually occurs in children and teens because their bones are flexible, unlike adults whose more brittle bones usually break.
Tibia shaft fractures are the most common long bone fractures. They account for approximately 4% of the fractures seen in the Medicare population.
Bone mineral density decreases with increasing age. Osteoporotic bone loss can be prevented through an adequate intake of vitamin C and vitamin D, coupled with exercise and by being a non-smoker. A study by Cheng et al. in 1997, showed that greater bone density indicated less risk for fractures in the calcaneus.
In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture.
- A greenstick fracture occurs due to mechanical failure on the tension side. That is, since the bone is not so brittle as it would be in an adult, it does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex in the surface opposite the applied force.
- Growth plate injuries, as in Salter-Harris fractures, require careful treatment and accurate reduction to make sure that the bone continues to grow normally.
- Plastic deformation of the bone, in which the bone permanently bends, but does not break, also is possible in children. These injuries may require an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.
- Certain fractures mainly occur in children, including fracture of the clavicle and supracondylar fracture of the humerus.
Complications are likely to result in cases of excess blood loss or punctures to certain organs, possibly leading to shock. Swelling and bruising may result, more so in high-impact injuries. Pain in the affected areas may differ where severity of impact increases its likelihood and may radiate if symptoms are aggravated when one moves around.
The healing time for a routine mandible fractures is 4–6 weeks whether MMF or rigid internal fixation (RIF) is used. For comparable fractures, patients who received MMF will lose more weight and take longer to regain mouth opening, whereas, those who receive RIF have higher infection rates.
The most common long-term complications are loss of sensation in the mandibular nerve, malocclusion and loss of teeth in the line of fracture. The more complicated the fracture (infection, comminution, displacement) the higher the risk of fracture.
Condylar fractures have higher rates of malocclusion which in turn are dependent on the degree of displacement and/or dislocation. When the fracture is intracapsular there is a higher rate of late-term osteoarthritis and the potential for ankylosis although the later is a rare complication as long as mobilization is early. Pediatric condylar fractures have higher rates of ankylosis and the potential for growth disturbance.
Rarely, mandibular fracture can lead to Frey's syndrome.
Smokers generally have lower bone density than non-smokers, so have a much higher risk of fractures. There also is evidence that smoking delays bone healing.
Several precautions may decrease the risk of getting a pelvic fracture. One study that examined the effectiveness of vitamin D supplementation found that oral vitamin D supplements reduced the risk of hip and nonvertebral fractures in older people. Certain types of equipment may help prevent pelvic fractures for the groups which are most at risk.
A compound elevated skull fracture is a rare type of skull fracture where the fractured bone is elevated above the intact outer table of the skull. This type of skull fracture is always compound in nature. It can be caused during an assault with a weapon where the initial blow penetrates the skull and the underlying meninges and, on withdrawal, the weapon lifts the fractured portion of the skull outward. It can also be caused the skull rotating while being struck in a case of blunt force trauma, the skull rotating while striking an inanimate object as in a fall, or it may occur during transfer of a patient after an initial compound head injury.
Mandible fracture causes vary by the time period and the region studied. In North America, blunt force trauma (a punch) is the leading cause of mandible fracture whereas in India, motor vehicle collisions are now a leading cause. On battle grounds, it is more likely to be high velocity injuries (bullets and shrapnel). Prior to the routine use of seat belts, airbags and modern safety measures, motor vehicle collisions were a leading cause of facial trauma. The relationship to blunt force trauma explains why 80% of all mandible fractures occur in males. Mandibular fracture is a rare complication of third molar removal, and may occur during the procedure or afterwards. With respect to trauma patients, roughly 10% have some sort of facial fracture, the majority of which come from motor vehicle collisions. When the person is unrestrained in a car, the risk of fracture rises 50% and when an unhelmeted motorcyclist the risk rises 4-fold.
In the US, the annual incidence of stress fractures in athletes and military recruits ranges from 5% to 30%, depending on the sport and other risk factors. Women and highly active individuals are also at a higher risk. The incidence probably also increases with age due to age-related reductions in bone mass density (BMD). Children may also be at risk because their bones have yet to reach full density and strength. The female athlete triad also can put women at risk as disordered eating and osteoporosis can cause the bones to be severely weakened.
A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and the middle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.
Compound fractures may either be clean or contaminated. Intracranial air (pneumocephalus) may occur in compound skull fractures.
The most serious complication of compound skull fractures is infection. Increased risk factors for infection include visible contamination, meningeal tear, loose bone fragments and presenting for treatment more than eight hours after initial injury.
Hyoid bones fractures represent 0.002% of all fractures; they are rare because the hyoid bone is well-protected by its location in the neck behind the mandible and in front of the cervical spine, as well as its mobility. 91.3% of hyoid bone fractures occur in men.
In 1991, Kathol conducted a study which showed a correlation between calcaneal insufficiency avulsion fractures (a fracture in which the Achilles tendon removes a portion of the bone as it rescinds) and diabetes mellitus. The diabetic population is more susceptible to the risks of fracture and potential healing complications and infection that may lead to limb amputation. Diabetes can be regulated and prevented through diet and exercise.
Bone stability after a fracture occurs between 3 and 4 weeks. Some experts suggest not wearing glasses or blowing the nose during this time as it can affect the bone alignment. Full bone fusion occurs between 4 and 8 weeks. General activity is fine after 1–2 weeks, but contact sports are not advisable for at least 2–3 months, depending on the extent of injury. It is recommended that when participating in sports a face guard should be worn for at least 6 weeks post-injury.
By definition, a nonunion will not heal if left alone. Therefore the patient's symptoms will not be improved and the function of the limb will remain impaired. It will be painful to bear weight on it and it may be deformed or unstable. The prognosis of nonunion if treated depends on many factors including the age and general health of the patient, the time since the original injury, the number of previous surgeries, smoking history, the patient's ability to cooperate with the treatment. In the region of 80% of nonunions heal after the first operation. The success rate with subsequent surgeries is less.
Clavicle fractures occur at 30–64 cases per 100,000 a year and are responsible for 2.6–5.0% of all fractures. This type of fracture occurs more often in males. About half of all clavicle fractures occur in children under the age of seven and is the most common pediatric fracture. Clavicle fractures involve roughly 5% of all fractures seen in hospital emergency admissions. Clavicles are the most commonly broken bone in the human body.
A Salter–Harris fracture is a fracture that involves the epiphyseal plate or growth plate of a bone. It is a common injury found in children, occurring in 15% of childhood long bone fractures.
Acute injury to the internal carotid artery (carotid dissection, occlusion, pseudoaneurysm formation) may be asymptomatic or result in life-threatening bleeding. They are almost exclusively observed when the carotid canal is fractured, although only a minority of carotid canal fractures result in vascular injury. Involvement of the petrous segment of the carotid canal is associated with a relatively high incidence of carotid injury.
As many as 50–70% of people who survive traffic accidents have facial trauma. In most developed countries, violence from other people has replaced vehicle collisions as the main cause of maxillofacial trauma; however in many developing countries traffic accidents remain the major cause. Increased use of seat belts and airbags has been credited with a reduction in the incidence of maxillofacial trauma, but fractures of the mandible (the jawbone) are not decreased by these protective measures. The risk of maxillofacial trauma is decreased by a factor of two with use of motorcycle helmets. A decline in facial bone fractures due to vehicle accidents is thought to be due to seat belt and drunk driving laws, strictly enforced speed limits and use of airbags. In vehicle accidents, drivers and front seat passengers are at highest risk for facial trauma.
Facial fractures are distributed in a fairly normal curve by age, with a peak incidence occurring between ages 20 and 40, and children under 12 suffering only 5–10% of all facial fractures. Most facial trauma in children involves lacerations and soft tissue injuries. There are several reasons for the lower incidence of facial fractures in children: the face is smaller in relation to the rest of the head, children are less often in some situations associated with facial fractures such as occupational and motor vehicle hazards, there is a lower proportion of cortical bone to cancellous bone in children's faces, poorly developed sinuses make the bones stronger, and fat pads provide protection for the facial bones.
Head and brain injuries are commonly associated with facial trauma, particularly that of the upper face; brain injury occurs in 15–48% of people with maxillofacial trauma. Coexisting injuries can affect treatment of facial trauma; for example they may be emergent and need to be treated before facial injuries. People with trauma above the level of the collar bones are considered to be at high risk for cervical spine injuries (spinal injuries in the neck) and special precautions must be taken to avoid movement of the spine, which could worsen a spinal injury.
Since approximately one third of the tibia lies directly beneath the skin, open fractures are common compared to other long bones. These open fractures are most commonly caused by high velocity trauma (e.g. motor vehicle collisions), while closed fractures most commonly occur from sports injuries or falls. Osteoporosis can be a contributing factor. Skiing and football (soccer) injuries are also common culprits.
Neck trauma, commonly by strangulation, athletic activities, and car accidents, is the cause of a hyoid bone fracture. Other causes include violent vomiting, gunshot wounds, and hanging.