Causes

What causes a bone to break?

We can think of this in three ways:

 situations in which fractures are most likely to happen

 mechanical forces that actually cause the bones to break
 risk factors that make some people more likely to have a fracture

Situations

When the bones are normal, breaks occur when they are subjected to unusually high forces. We often divide these
situations into High and Low Energy causes. High Energy trauma is caused by motor vehicle accidents, falls from
heights and violence (e.g., gunshot wound - GSW) and the injuries are more likely to be multiple.

Low Energy trauma results from falls, childhood play and most sports injuries. The breaks caused by these type of
events tend to be localized to one bone or area.

Mechanical Forces

Most times a combination of forces is applied to bones to cause the fracture. Here we simplify the situation to
explain what would happen if only one type of force occurred.

Avulsion
Muscles, ligaments, and tendons attach to bone. If they pull too hard the bony attachment may break off. This
happens most commonly when joints such as the knee or elbow dislocate, imposing severe strains on the
ligaments that normally hold the joint together. It can also happen from the direct pull of a muscle in the spine,
shoulder, elbow, hand, hip, knee, heel, or foot. This is usually a low energy injury but the result may depend on
healing the pulled-off piece of bone back to the correct place.

Compression

Crushing forces can cause fractures in the vertebrae, knee and heel bone (sometimes together) when you land on
your feet after a fall. These bones tend to squash down. This is called "impacted". When compression is applied
along the length of a long bone you tend to get a transverse fracture pattern. This is quite common in the forearm
(low energy) and the thighbone (high energy) but can occur in any long bone. The fracture fragments are often
displaced and overlapped.

Twisting

A twist severe enough to break a long bone results in a spiral fracture pattern. This is particularly common in the
lower leg bone (tibia) and the upper arm bone (humerus). It takes less force to break a bone by twisting it so most
of these injuries are low energy. However the amount of displacement at the time of injury can be spectacular and
there is often a significant soft tissue component to the injury. Twisting forces near joints can cause fractures; the
ankle is a common example.

Bending
Bending forces can be applied either by a direct impact on the middle of a bone or by opposing forces being
applied to each end of the bone. In a pedestrian vs motor vehicle accident, for example, the fender of the vehicle
may strike the pedestrian’s shin with force enough to bend and break the bone. This is a high energy injury and the
bone often breaks out through the skin in this situation (see open fracture below). In a fall on the outstretched
hand (FOOSH) the downward momentum of the body weight is applied to the elbow end of the bone and the
upward ground reaction force is applied to the hand end. The result is bending of the forearm bones and a low
energy bending fracture of the wrist, forearm or elbow. The fracture is often angulated. At the wrist and elbow
there is usually a compression element as well.

Violence

Blast and gunshot injuries cause severe fractures with major open wounds, splintering of the bone and terrible
damage to the muscles. Blood vessels and nerves are often torn by the spreading shockwave from projectiles. Child
abuse causes injuries in a depressingly large number of cases and recognition is very important. The fractures
themselves are less of a problem than the danger the child faces if the situation is not discovered. Twisting
fractures in infants need to be carefully evaluated because they don’t often occur in the normal course of events.

Risk Factors

There are a variety of reasons why some people are more likely than others to have a fracture. Either their bones
are weaker or they undertake riskier activities.

Behavior

Four groups of people have markedly higher risks of breaking bones. The elderly are more likely to fall, particularly
if they are also confused. Their bones are more fragile too. Young adult and post-teen males are more likely to take
risks on the road, at work and play. They too have a higher than normal risk of fracture. The third group is children
at play. The normal rough and tumble of childhood does increase the risk of fracture. With fortunately few
exceptions fractures in children heal well and without long-term problems. People with substance abuse problems
also have a higher risk of suffering a fracture because of lifestyle issues and higher risk of falling.

Bone abnormality

Bone is a living tissue made up of a gristly matrix hardened by calcium. Both the matrix and the calcium salts are
slowly reabsorbed and re-deposited by living bone cells. This is called bone remodelling. Bone remodelling is a
normal process occurs constantly throughout our lives. As with all living tissue, the normal situation can be altered
by disease processes. This usually leaves the bone weaker than normal.

Osteoporosis and other Metabolic Bone Diseases

In the elderly, bone gets steadily thinner and weaker. The metabolic balance of bone changes. Less new bone is
laid down and more old bone is reabsorbed. The bone gets weaker and weaker with time. Certain metabolic
diseases can make this process occur faster. The process of osteoporosis is the most common of several metabolic
bone diseases. Others are Paget's disease and osteomalacia in older people; rickets, osteogenesis imperfecta and
osteopetrosis usually are first noted in childhood.

Deposits in Bone

Bones are weakened when normal tissue is replaced by benign or malignant tumors. Benign deposits are the most
common in children. In adults, especially the elderly, secondary deposits from cancers that start elsewhere are
more common. Rarely, a fracture through a secondary deposit is the first sign that there is a cancer in the body. In
all age groups primary bone cancer, meaning that the cancer started first in the bone, is rare.

Types of thoraco-lumbar fractures

Wedge compression fractures are the most

common type of lumbar fracture (4). They occur during
hyperflexion and axial loading (as was likely in our
case). The vertebral body fails under a compressive
load and its anterior portion becomes compressed while
the middle column remains intact. This fracture is
rarely associated with neural injury unless multiple
adjacent vertebral bodies are compressed.
Radiographically, the wedge deformity is best
appreciated on the lateral view. A CT scan is used to
confirm that the posterior vertebral body, pedicles and
lamina are intact.
2. A burst fracture of the spine was first described
by Holdsworth (8) in 1963 and redefined by Denis (6) in
1983 as being a fracture of the anterior and middle
columns of the spine with or without an associated
posterior column fracture. Both a compression fracture
and burst fracture occur during hyperflexion and axial
loading of a vertebra. With a burst fracture, however,
there is compression of the vertebra and intervertebral
disk in such a fashion that the compressed disk
adjacent to the affected vertebra herniates into the
vertebral body. As a result, the vertebra fractures
outward with retropulsion of bone fragment into the
spinal canal and an increase in interpeduncular
distance (distance between the pedicles). Because all
burst fractures have the potential for severe neurologic
sequelae, they should be considered unstable during
the initial emergency department evaluation. Unstable
burst fractures are treated with surgical stabilization to
improve long-term alignment. For stable fractures, the
neurologic outcome may be similar for surgically and
non-surgically treated patients (1,4).
3. A Chance fracture is commonly associated with
lap seat belt use in high-speed motor vehicle crashes
(9). A Chance fracture is a horizontal vertebral injury
that results from flexion about an axis that is anterior to
the anterior spinal longitudinal ligament. This vector of
force results in the horizontal disruption of the spinous
process, lamina, transverse processes, pedicles and
the vertebral body. A lateral radiograph best illustrates
the split in the posterior arch and vertebral body. More
subtle signs include an increase in adjacent spinous
process distancec above and below the injury and an
increase in the height of the posterior vertebral body.
An anterior-posterior radiograph may demonstrate the
split in the transverse processes. Since the fracture
runs in an axial plane, a routine axial CT scan may miss
a Chance fracture. It is important to perform the
reconstruction in the sagital plane to detect the fracture
and any malalignment due to ligamentous injury.
4. A flexion distraction injury is one in which the axis
of flexion is posterior to the anterior spinal longitudinal
ligament. There is compressive failure of the anterior
column and destructive forces placed on the middle and
posterior columns lead to a tear of the posterior
longitudinal ligament. Typically, these injuries involve
both ligamentous and bony structures and can extend
over more than one vertebral level. These injuries are
considered unstable because the middle column and
often the posterior column are disrupted. Radiographic
findings include anterior impaction with compression
fracture of the vertebral body and posterior distraction
with fanning of the spinous processes.
5. Translational injuries are associated with
shearing forces that disrupt all three columns. The
shearing forces are most often directed posteriorly to
anteriorly but may also be directed anteriorly to
posteriorly. Since the ligament of the spinal canal is
affected, these injuries are always unstable and are
associated with a very high incidence of neurologic
deficit (6). Lateral radiographs demonstrate anterior
translation of the upper vertebrae with respect to the
lower vertebrae. On the AP radiograph, the
interspinous distance at the affected level is widened
and there may or may not be a rotational malalingment
of the vertebra. CT scan may show "naked facets" or a
double vertebra, if the dislocation is severe.