A clear and consistent description of an injury is essential for effective communication with colleagues, guiding treatment decisions, and estimating outcomes. This page explains how to accurately describe an (open) fracture, including the extent of the associated soft-tissue damage.

Describing an open fracture

An adequate description of an open fracture typically includes:

• The affected bone
• The location of the fracture within the bone
• The fracture pattern
• The degree of displacement
• Whether the fracture communicates with the external environment, and to what extent.

Description of the affected bone

Identify which bone is fractured. In high-energy trauma, remain alert for additional fractures in other locations. If multiple injuries are present, list each fractured bone separately.

Description of location

Open fractures most commonly involve the long bones. The location of the fracture can be described according to its position within the bone: Diaphyseal, metaphyseal, or epiphyseal.

Diaphyseal fractures (shaft fractures)

These fractures occur in the diaphysis, the shaft of a long bone, and do not involve the joint surface.

Metaphyseal fractures

These fractures occur in the metaphysis, the wider part of the bone near the end of a long bone. They are located close to the joint but do not involve the articular surface.

Epiphyseal (intra-articular).

Description of the fracture pattern

Fractures can present in different patterns. Each present unique challenges in diagnosis and treatment, requiring tailored medical approaches to ensure proper healing³. 

Transverse fracture

A transverse fracture is characterized by a fracture line perpendicular to the long axis of the bone, often resulting from a direct blow. Because of the straight fracture pattern, these fractures can be relatively stable compared with more oblique patterns, although displacement can still occur. The relatively small fracture surface area may also reduce bony contact, which can slow healing.

Oblique fracture

An oblique fracture is characterized by a running diagonal fracture line across the bone. These fractures are typically caused by an angled force or bending (e.g. fall or direct trauma). Because of the angled fracture surface, oblique fractures are generally less stable than transverse fractures, making reduction and maintenance of alignment more challenging.

Spiral fracture

A spiral fracture is characterized by a fracture line that encircles the long axis of the bone (like a corkscrew), caused by rotational forces. These fractures are commonly seen in long bones such as the tibia or femur. Because of the large fracture surface area, bone contact is relatively large, which may promote healing. However, similar to oblique fractures, the angled fracture plane means the fracture can be unstable and prone to displacement. When reducing a spiral fracture, make sure to pay special attention to the rotational alignment of the limb.

Comminuted fracture

A comminuted fracture is characterized by the bone breaking into three or more fragments. These fractures usually result from high-energy trauma, such as motor vehicle accidents or severe falls. Because of the multiple fragments and limited bone contact, the fracture is often unstable and healing may be more complex.

Segmental fracture

A segmental fracture is characterized by two separate fracture lines in the same bone, creating an isolated segment. These injuries usually result from high-energy trauma. Because the middle segment often has limited blood supply and no direct cortical contact with the main fragments, the fracture is highly unstable and healing can be difficult.

In late presenting cases - The segmental fragment may become avascular and eventually result in a large segmental bone defect.

Avulsion fracture

An avulsion fracture occurs when a tendon or ligament pulls a fragment of bone away from its attachment site. These injuries are typically caused by sudden forceful contraction or stretch and often occur near joints.

Impacted fracture

An impacted fracture occurs when the broken bone ends are driven into each other, usually due to axial compression such as during a fall. Because the fragments are forced together, the fracture can be relatively stable, although shortening of the bone may occur.

Describing displacement

Displacement is described relative to the original anatomical position of the bone. Mention:

Example of how to describe a fracture
The X-ray shows a displaced mid-shaft tibial spiral fracture with valgus angulation and minimal shortening.

Pediatric fracture types

Children’s bones differ from adult bones. As a result, fractures in children may present with different patterns and may require different treatment, even when the mechanism of injury is similar.

Our page on the differences between paediatric and adult bones: Bone anatomy

Incomplete fractures

Children are more prone to incomplete fractures, most commonly involving the radius and ulna. Common incomplete fractures include:

Buckle fracture

The bone is compressed, forcing the bone to bulge instead of break. Buckle fractures are caused by a sudden pressure in the longitudinal direction of the bone.

Greenstick fracture

Only one side of the cortex breaks. A greenstick fracture looks like you have tried to break a young green branch of a plant, hence the name. Greenstick fractures are caused by a bending force on the bone.

Bowing fractures

The affected bone shows bowing. Often these fractures are combined with another type of fracture. A longitudinal angulating force on the long bone is the primary trauma mechanism.

Metaphyseal growth plate fractures

Fractures in children can involve the growth plate.

These fractures are classified according to the Salter-Harris classification system. This will help you to estimate the risk of complications such as growth disturbance, limb length discrepancy, and angular deformity, and guides appropriate treatment and prognosis.

The classification consists of five main types of fracture, which you can remember using the mnemonic SALTR: Straight, Above, Lower, Through, Rammed.

Open vs closed fractures

The fractures described earlier all involve closed fractures. Meaning that there is no disruption of the skin in these fractures. However sometimes it happens that there is a wound with a connection to the fracture. Leading to an open connection between the fracture sight in the body and the outside environment. One of the important consequences of this is a high risk of infection and impaired bone repair due to this infection.

That is why it is important to besides using the descriptive tools for fractures as mentioned above to state if it concerns an open or a closed fracture.

The main aim of a grading system is to help guide treatment, predict outcome and simplify communication in research. The most commonly used system is the Gustillo-Anderson classification for open fractures. This system was updated with an extra addition to the grade III group. However also this grading system has its limitations. Those include: limited inter-observer reliability and the system uses the surface wound as an indication of severity. While the surface wound does not always correlate with the extend of the soft tissue injuries. (Kim & Leopold, 2012) Keeping this in mind we will discuss the grading system below.

The Gustilo-Anderson Classification

This classification uses three grades, and mainly focusses on the soft tissue injury visible from the outside and the fracture pattern to determine which grade the open fracture falls into.