FRACTURE

A bone fracture (sometimes abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a break in the continuity of the bone. A bone fracture can be the result of high force impact or stress, or trivial injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, bone cancer, orosteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture. Although broken bone and bone break are common colloquialisms for a bone fracture, break is not a formal orthopedic term. Bone is the strong tissue that forms the basis of your skeleton. It is a living tissue, made up of bone-forming cells, which produce the mineral compound (matrix) that makes your bones strong and hard. Your bones can usually tolerate external forces (for example, knocking a bone as a result of a fall or injury) but if the force is very big or your bones are weak, they may crack or break into fragments. TYPES OF FRACTURE In orthopedic medicine, fractures are classified in various ways. Historically they are named after the doctor who first described the fracture conditions. However, there are more systematic classifications in place currently. All fractures can be broadly described as: Closed (simple) fractures are those in which the skin is intact Open (compound) fractures involve wounds that communicate with the fracture, or where fracture hematoma is exposed, and may thus expose bone to contamination. Open injuries carry a higher risk of infection.

Other considerations in fracture care are displacement (fracture gap) and angulation. If angulation or displacement is large, reduction (manipulation) of the bone may be required and, in adults, frequently requires surgical care. These injuries may take longer to heal than injuries without displacement or angulation. Compression fractures usually occur in the vertebrae, for example when the front portion of a vertebra in the spine collapses due to osteoporosis (a medical condition which causes bones to become brittle and susceptible to fracture, with or without trauma).

Other types of fracture are: Complete fracture: A fracture in which bone fragments separate completely. Incomplete fracture: A fracture in which the bone fragments are still partially joined. In such cases, there is a crack in the osseous tissue that does not completely traverse the width of the bone. Linear fracture: A fracture that is parallel to the bone's long axis. Transverse fracture: A fracture that is at a right angle to the bone's long axis. Oblique fracture: A fracture that is diagonal to a bone's long axis. Spiral fracture: A fracture where at least one part of the bone has been twisted. Comminuted fracture: A fracture in which the bone has broken into a number of pieces. Impacted fracture: A fracture caused when bone fragments are driven into each other.

INDICATIONS OF PRESENCE First know what happened. If the victim thinks he has a broken bone, or if he was unconscious after an accident try to find out. Signs and symptoms Although bone tissue itself contains no nociceptors, bone fracture is very painful for several reasons:

Breaking in the continuity of the periosteum, with or without similar discontinuity in endosteum, as both contain multiple nociceptors. Edema of nearby soft tissues caused by bleeding of torn periosteal blood vessels evokes pressure pain. Muscle spasms trying to hold bone fragments in place

Damage to adjacent structures such as nerves or vessels, spinal cord and nerve roots (for spine fractures), or cranial contents (for skull fractures) can cause other specific signs and symptoms. At the site of the fracture you may also notice:

swelling bruising the bone sticking out or bending a grating feeling or sound

pain upon moving the area above the injured part dislocation tenderness

You may also become pale and clammy, and feel sick or light-headed due to the pain. If you think you have a fracture, you should go to your nearest accident and emergency department or call for an ambulance if you are unable to move. PATHOPHYSIOLOGY The natural process of healing a fracture starts when the injured bone and surrounding tissues bleed, forming a fracture Hematoma. The blood coagulates to form a blood clot situated between the broken fragments. Within a few days blood vessels grow into the jelly-like matrix of the blood clot. The new blood vessels bring phagocytes to the area, which gradually remove the non-viable material. The blood vessels also bring fibroblasts in the walls of the vessels and these multiply and produce collagen fibers. In this way the blood clot is replaced by a matrix of collagen. Collagen's rubbery consistency allows bone fragments to move only a small amount unless severe or persistent force is applied. At this stage, some of the fibroblasts begin to lay down bone matrix (calcium hydroxyapatite) in the form of insoluble crystals. This mineralization of the collagen matrix stiffens it and transforms it into bone. In fact, bone is a mineralized collagen matrix; if the mineral is dissolved out of bone, it becomes rubbery. Healing bone callus is on average sufficiently mineralized to show up on X-ray within 6 weeks in adults and less in children. This initial "woven" bone does not have the strong mechanical properties of mature bone. By a process of remodeling, the woven bone is replaced by mature "lamellar" bone. The whole process can take up to 18 months, but in adults the strength of the healing bone is usually 80% of normal by 3 months after the injury. Several factors can help or hinder the bone healing process. For example, any form of nicotine hinders the process of bone healing, and adequate nutrition (including calcium intake) will help the bone healing process. Weight-bearing stress on bone, after the bone has healed sufficiently to bear the weight, also builds bone strength. Although there are theoretical concerns about NSAIDs slowing the rate of healing, there is not enough evidence to warrant withholding the use of this type analgesic in simple fractures. COMPLICATIONS Fractures can sometimes cause a number of additional problems. Your fracture may damage surrounding structures, such as your nerves or a blood vessel. You may need special treatment if this happens. Your fracture may become infected. This is more common if you have an open fracture or if you need surgery to fix it. If your fracture becomes infected, it may take longer to heal and there is a chance that your bone will become infected. This is called osteomyelitis - see Related topics for more information

CAUSES Fractures usually occur if you hit your bone or if you twist or bend awkwardly. This can happen as a result of a fall or a collision. Fractures are more common in young children because they tend to have more falls and accidents, partly because they are less aware of hazards. You may fracture a bone without an obvious trauma. For example, athletes are more at risk of getting stress fractures, as these can happen with repeated stress over time. You're also more likely to break a bone as you get older or if you have a disease that weakens your bones. DIAGNOSIS At the hospital, your doctor will ask about your symptoms and examine you for signs of a fracture, such as swelling or if your bones are held in an unusual position. He or she will usually use X-rays to diagnose your fracture. However, if a fracture doesn't show up clearly on the X-ray, your doctor may request an MRI (magnetic resonance imaging) or CT (computerized tomography) scan to look at it more closely. Your doctor may also ask you to have some blood tests to check for conditions that can weaken your bones. TREATMENT You should always seek medical attention if you think you may have broken a bone. However, there are some things you can do to reduce your pain and prevent further injury until you see a doctor. First aid If you break your arm, you can secure the bone with a sling or a splint to help reduce the pain and prevent further injury, until you receive medical help. You can also take painkillers to ease the pain. Always read the patient information leaflet that comes with the medicine and ask your pharmacist or doctor for advice. Pain management In arm fractures in children, ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine. Immobilization Since bone healing is a natural process which will most often occur, fracture treatment aims to ensure the best possible function of the injured part after healing. Bone fractures are typically treated by restoring the fractured pieces of bone to their natural positions (if necessary), and maintaining those positions while the bone heals. Often, aligning the bone, called reduction, in good position and verifying the improved alignment with an X-ray is all that is needed. This process is extremely painful without anesthesia, about as painful as breaking the bone itself. To this end, a fractured limb is usually immobilized with a plaster or fiberglass cast or splint which holds the bones in position and immobilizes the joints above and below the fracture. When the initial post-fracture edema or swelling goes down, the fracture may be placed in a removable

brace or orthosis. If being treated with surgery, surgical nails, screws, plates and wires are used to hold the fractured bone together more directly. Alternatively, fractured bones may be treated by the Ilizarov method which is a form of external fixator. Occasionally smaller bones, such as phalanges of the toes and fingers, may be treated without the cast, by buddy wrapping them, which serves a similar function to making a cast. By allowing only limited movement, fixation helps preserve anatomical alignment while enabling callus formation, towards the target of achieving union. Splinting results in the same outcome as casting in children who have a distal radius fracture with little shifting. Surgery Surgical methods of treating fractures have their own risks and benefits, but usually surgery is done only if conservative treatment has failed or is very likely to fail. With some fractures such as hip fractures (usually caused by osteoporosis or osteogenesis Imperfecta), surgery is offered routinely, because the complications of non-operative treatment include deep vein thrombosis (DVT) and pulmonary embolism, which are more dangerous than surgery. When a joint surface is damaged by a fracture, surgery is also commonly recommended to make an accurate anatomical reduction and restore the smoothness of the joint. Infection is especially dangerous in bones, due to the recrudescent nature of bone infections. Bone tissue is predominantly extracellular matrix, rather than living cells, and the few blood vessels needed to support this low metabolism are only able to bring a limited number of immune cells to an injury to fight infection. For this reason, open fractures and osteotomies call for very careful antiseptic procedures and prophylactic antibiotics. Occasionally bone grafting is used to treat a fracture. Sometimes bones are reinforced with metal. These implants must be designed and installed with care. Stress shielding occurs when plates or screws carry too large of a portion of the bone's load, causing atrophy. This problem is reduced, but not eliminated, by the use of lowmodulus materials, including titanium and its alloys. The heat generated by the friction of installing hardware can easily accumulate and damage bone tissue, reducing the strength of the connections. If dissimilar metals are installed in contact with one another (i.e., a titanium plate with cobalt-chromium alloy or stainless steel screws), galvanic corrosion will result. The metal ions produced can damage the bone locally and may cause systemic effects as well. Electrical bone growth stimulation or osteostimulation has been attempted to speed or improve bone healing. Results however do not support its effectiveness. Physical therapies Once your fractured bone has been set in place, you will need to build up the strength in the bone. Your doctor may suggest you begin with some gentle exercises or refer you to a physiotherapist. Physiotherapy can help promote healing and increase your movement of the affected area.

After your treatment You should return to the fracture clinic or accident and emergency department at the hospital as soon as possible if:

you continue to have pain your swelling doesn't go down and your toes or fingers turn bluish your fracture has an offensive smell or discharge your cast has been damaged (e.g. it has softened because it got wet) your skin has become increasingly red around the wounds

COMPLICATIONS Some fractures can lead to serious complications including a condition known as compartment syndrome. If not treated, compartment syndrome can result in amputation of the affected limb. Other complications may include non-union, where the fractured bone fails to heal or mal-union, where the fractured bone heals in a deformed manner.