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FRACTURES

1. Definition A linear deformation or discontinuity of bone produced by forces exceeding the modulus of elasticity of the bone. It is a complete or incomplete break in the continuity of a bone with associated soft tissue injury.

2. Epidemiology
The epidemiology of osteoporosis-related fractures includes factors related to underlying osteoporosis and those related to injury, such as age and falling. Vertebral fracture incidence rises rapidly from the 50s and thereafter, whereas hip fracture risk rises most dramatically from the decade of the 70s and thereafter

Almost all fractures are osteoporotic, in that the risk of fracture increases as bone density decreases, with the few exceptions being fractures of the skull, fingers, and toes. Increased risks of falling, as well as progressive loss of bone are 2 of the factors responsible for the increasing risk of fracture with advancing age. Although traumatic fractures, such as those associated with motor vehicle accidents, may also be more common in people with lower bone mass, these are generally not considered to be osteoporotic. In most parts of the world and for almost all ethnic groups, women have a higher risk of fractures than men. A history of prior fractures is an extremely important predictor of the risk of future fractures, regardless of bone density. A history of vertebral fracture increases subsequent spine fracture risk by 5 times and nonspine fracture occurrence (including hip fracture) by 2 times. The natural history of vertebral fracture occurrence suggests a clustering of vertebral fracture events, with a future risk of 20% in the year following an incident vertebral fracture in women on no active osteoporosis medication. Patients presenting with hip fractures are several times more likely to have had 1 or more vertebral fractures, and twice as likely to have had a Colles fracture

3. Etiology A. Pathologic Fracture Any local or general disease that causes the bone to become unduly brittle which predisposes fracture even with minimal traumatic force. children may be due to a cyst or benign tumor older age groups systemic conditions such as lack of calcium ions(i.e. Pagets disease, osteomyelitis and osteoporosis) B. Traumatic Fracture

External Causative Factors Violence/Trauma the bone is normal but the causative force is maximal Direct Violence due to blows or falls to which break occurs at the point of impact with the ground or the object Indirect Violence occurs when the force is transmitted to the bone through some parts of the body such as a fall to the outstretched hand causing a fracture on the upper arm or of bones of the legs from falls upon feet Internal Causative Factors Muscular action ex. a fracture in the patella due to a sudden contraction of the quadriceps; fracture of the arm in throwing a ball or fracture of the humerus of women wringing clothes 4. Pathophysiology In fracture, the actual damage to the bone consist of a break in the continuity which results in damage to blood and lymphatic vessels. Tiny bone fragments cut-off from their normal blood supply usually die. The periosteum will be stripped off on the region of the injury. The tiny vessels passing over the injury are ruptured. sometimes the preisteum is torn but since it is a tough fibrous membrane, it may remain intact. An intact preiosteum is essential because it traps the blood from the ruptured vessel which is essential for hematoma formation needed in the repair process. Due to the sharp edges of the broken bone or the force impacted upon the body part, there are damages on the surrounding soft tissues like the torn muscle, muscle tearing of fascia and other connective tissues, ruptured blood vessels and considerable extravasation of blood will take place. Tissue debris and blood clots act as irritants and an inflammatory reaction occurs, neighboring small vessels dilate and hyperemia results and area affected is invaded by inflammatory cells. Some salts are absorbed and decalcification of the fracture bone ends may occur. The excess calcium is found in the blood and in the inflammatory fluid surrounding.

5. Clinical Signs and Symptoms Abnormal mobility motion in a limb at a point in a direction in which it does not normally reach Crepitus the grating sound or sensation produced by the friction of one fragment moving on the other. One of the most reliable diagnostic sign.

Swelling in the vicinity of the fracture is the result of extravasation of blood and serum into the tissue. The degree of swelling varies with the extent of tissue injury and vascular injury and the length of time since the injury. IN the open fracture, the swelling is not a prominent feature, as the blood escapes through the wound. Bruising or ecchymosis the presence of blood in the subcutaneous tissue and leads to discoloration in the tissue. It is almost present in a fracture, but it is not to be regarded as an important symptom in an acute fracture, because the ecchymosis may not appear until 2 to 3 days after the injury. Deformity signifies a change in the shape or position of the limb which is due to alterations in the body structure. Search for the deformity should be the first step. The injured limb and its contralateral side should be placed in the same relative positions and should then be compared by inspection, palpation and measurement. Pain at the time of injury and afterwards, both spontaneous and upon movement of fixed limb is a constant accompaniment of fracture, but the degree of pain varies considerably in different fractures and in different persons with similar fracture. Tenderness amount of tenderness varies greatly in different persons and also varies directly with the amount of injury to the soft tissue and with the time elapsing after the injury. Absence of active movement Muscle spasm during attempt to move the extremity Characteristic of attitude Soft tissue edema present in surrounding structure; reaction due to the trauma of the fracture, may/may not be indicative of the severity of the underlying damage; area surrounding fracture site may feel warm to the touch. Excessive motion at the site of fracture; present especially if site is not near a joint or is not splintered by surrounding soft tissue structure Open wounds may sometimes mask degree of damage Neurovascular Impairment due to fragmentation of bone and soft tissue alteration

6. Differential Diagnosis
Fibrous Dysplasia Fibrous Histiocytoma Gaucher's Disease Giant Cell Tumor of Bone Metastatic Tumors to Bone (most common) Metastatic Breast Cancer: Multiple Myeloma Nonossifying fibroma Osteogenesis Imperfecta Osteomalacia Osteomyelitis: Osteoporosis Osteopetrosis Pagets Disease Renal Osteodystrophy Simple Bone Cyst / Unicameral

7. Complications

8. Medical and Surgical Management 9. DETAILED PT Assessment 10. PT Management