Traumatic fractures are usually the result of a severe force acting from without, although sometimes they are produced by muscular contraction.
Fig. 1.—Multiple Fracture of both Bones of Leg.
When the bone gives way at the point of impact of the force, the violence is said to be direct, and a “fracture by compression” results, the line of fracture being as a rule transverse. The soft parts overlying the fracture are more or less damaged according to the weight and shape of the impinging body. Fracture of both bones of the leg from the passage of a wheel over the limb, fracture of the shaft of the ulna in warding off a stroke aimed at the head, and fracture of a rib from a kick, are illustrative examples of fractures by direct violence.
When the force is transmitted to the seat of fracture from a distance, the violence is said to be indirect, and the bone is broken by “torsion” or by “bending.” In such cases the bone gives way at its weakest point, and the line of fracture tends to be oblique. Thus both bones of the leg are frequently broken by a person jumping from a height and landing on the feet, the tibia breaking in its lower third, and the fibula at a higher level. Fracture of the clavicle in its middle third, or of the radius at its lower end, from a fall on the outstretched hand, are common accidents produced by indirect violence. The ribs also may be broken by indirect violence, as when the chest is crushed antero-posteriorly and the bones give way near their angles. In fractures by indirect violence the soft parts do not suffer by the violence causing the fracture, but they may be injured by displacement of the fragments.
In fractures by muscular action the bone is broken by “traction” or “tearing.” The sudden and violent contraction of a muscle may tear off an epiphysis, such as the head of the fibula, the anterior superior iliac spine, or the coronoid process of the ulna; or a bony process may be separated, as, for example, the tuberosity of the calcaneus, the coracoid process of the scapula, or the larger tubercle (great tuberosity) of the humerus. Long bones also may be broken by muscular action. The clavicle has snapped across during the act of swinging a stick, the humerus in throwing a stone, and the femur when a kick has missed its object. Fractures of ribs have occurred during fits of coughing and in the violent efforts of parturition.
Before concluding that a given fracture is the result of muscular action, it is necessary to exclude the presence of any of the diseased conditions that lead to pathological fracture.
Although the force acting upon the bone is the primary factor in the production of fractures, there are certain subsidiary factors to be considered. Thus the age of the patient is of importance. During infancy and early childhood, fractures are less common than at any other period of life, and are usually transverse, incomplete, and of the nature of bends. During adult life, especially between the ages of thirty and forty, the frequency of fractures reaches its maximum. In aged persons, although the bones become more brittle by the marrow spaces in their interior becoming larger and filled with fat, fractures are less frequent, doubtless because the old are less exposed to such violence as is likely to produce fracture.
Males, from the nature of their occupations and recreations, sustain fractures more frequently than do females; in old age, however, fractures are more common in women than in men, partly because their bones are more liable to be the seat of fatty atrophy from senility and disease, and partly because of their clothing—a long skirt—they are more exposed to unexpected or sudden falls.