Comminuted fractures are complex fractures resulting from severe impact, in which the bone has been fragmented, shattered or crushed into several fragments. Orthopedic surgery, necessary to put the bone back in place and prevent the displacement of fragments, is often delicate. The risk of complications and sequelae is higher than for simple fractures.

Definition

Any fracture is unique and defined by its site, by the direction of the fracture line (s) as well as by the number of fragments generated and by their displacement.

Complex fractures can thus be three-fragment (“butterfly-wing” fractures) or double-stage. When the fracture is multi-fragmentary, we speak of a comminuted fracture (from the Latin comminuere, to break).

Sometimes the bone literally shattered from the violence of the impact into numerous fragments or splinters. When the fragments overlap, the fracture is said to be meshed.

Comminuted fractures can affect any bone. However, some are more at risk of breaking into several fragments. Patella fractures, in particular, as well as crush fractures of the metatarsals and phalanges of the foot, or compression fractures of the calcaneus (heel), are often comminuted. 

Among other comminuted fractures, we can distinguish, among others:

• The burst fracture, located in the spine. It is linked to the hyperflexion-compression of the spine, which causes the bursting of a vertebra.
• Rolando’s fracture, a comminuted fracture of the base of the 1st metacarpal (thumb).

Causes

Adult commitative fractures are serious injuries that result from direct or indirect high-energy shock. In elderly people with more fragile bones, they can be observed after a banal fall (neck of the femur, wrist, etc.).

Diagnostic

The clinical signs and the circumstances of the accident can give a strong presumption as to the presence of a fracture and predict its severity, but imaging examinations are still necessary.

X-rays are not always sufficient to characterize comminuted fractures. A CT scan or an MRI may be requested to refine the diagnosis.

The people concerned

All age groups can be affected, but young men are more frequently affected by comminuted fractures caused by high-energy accidents, and women over 60, affected by osteoporosis after menopause, by those arising from a low energy shock.

Risk factors 

Certain circumstances favor the occurrence of these fractures: road accidents, and to a lesser extent those at work (crushing, falling from a great height) or those linked to sports. Burst fractures of the spine, for example, are well known to hospital services located near ski resorts!

In the elderly, balance problems promote falls.

A fracture manifests itself by different signs on physical examination:

• visible displacement of the bone (abnormal angle),
• edema and hematoma following lesions of the blood vessels,
• sensitivity to touch,
• acute pain on movement,
• inability to mobilize the member concerned,
• open wound, etc.

These symptoms may be increased in the event of a comminuted fracture.

External maneuvers usually reduce a simple fracture, after which the properly immobilized bone repairs itself. On the other hand, surgery is required when it is fractured in several places, because the bone fragments may move.

Osteosynthesis

This intervention performed by the orthopedic surgeon and traumatologist aims to keep the fragments of bone put back in place during the time of consolidation. Performed under general or local anesthesia, it can be very delicate.

The intervention is performed under general or local anesthesia. The surgeon uses metal material in steel, titanium or alloys (with cobalt, nickel or chromium): plates and screws which are positioned on the surface of the fragments as well as nails driven into the central channel of the bone (nailing) and pins that go through the bone. The constitution of bone callus (newly formed bone tissue during consolidation) should make it possible to fill the voids and integrate the unfixed fragments.

When the fractures are too complex to allow direct fixation, the rods that pass through a fractured limb can be fixed to a external fixator, composed of two metal bars.

Some metal implants will be removed under local anesthesia a few weeks after the operation, others will remain in place.

If osteoynthesis is not possible, bone grafts or the use of a prosthesis are possible in certain cases.

Early complications

The risk of complications varies depending on the context of the fracture, and may require the intervention of a multidisciplinary team, especially in patients with multiple trauma or in intensive care.

• While muscle damage associated with the fracture is often benign, vascular and nerve damage should be detected immediately.
• Fragments from comminuted fractures in the rib cage may pose a risk to the lungs or heart, those from burst fractures of the spine, which can cause neurological damage.
• The risk of infection, increased in the event of an open fracture, justifies the administration of antibiotics.
• Anticoagulant prophylaxis and early mobilization of the limb are recommended to combat the risk of phlebitis.

Late complications and sequelae

Consolidation of a fracture in a bad position – vicious callus – or a secondary displacement of the bone may require a new surgical intervention.

The treatment of dystrophy, frequent following such traumas, is essentially based on physiotherapy.

Internal fixation does not always make it possible to restore the bone “identically” and the sequelae are not rare: stiffness and reduced function, osteoarthritis, etc.

The treatment of osteoarthritis is based on drugs (analgesics and anti-inflammatory drugs, corticosteroid infiltration, etc.) and on physiotherapy. Hydrotherapy, acupuncture or mesotherapy can help relieve pain. Homeopathy or herbal medicine can also be tried.