BONE FRACTURES A fracture is a complete or incomplete break in a bone resulting from the application of excessive force. A bone fracture is a medical condition in which there is a break in the continuity of the bone. They are injuries of bone tissue, which compromise their ability to support the body. It 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, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.
BONE FRACTURE PHYSIOLOGY Bone tissue is structurally very hard, but when it is subjected to forces higher than its capacity it responds in two ways. When the forces are applied in one instant, like a sudden fall, it results in a bone fracture. But if it is applied slowly over a period of time, it results in remodeling of the bone to a shape that balances the forces e. g. bowing of legs in rickets. Thus, the bone has a dynamic nature and adjusts to the changing loads of weight bearing and physical stress.
This ability of bones is due to the constant erosion of bone by osteoclasts and deposition of new bone by osteoblasts (Picture 1). Picture 1: Bone Fracture Physiology A delicate balance between these cells is responsible for thickening or thinning of bones, depending on the activity performed by a person. Hence, a manual laborer has a much sturdy skeleton than a sedentary working clerk in an office. Thus, after a bone fracture, the bones have an intrinsic ability to heal themselves due to the deposition of bone by osteoblasts.
It also indicates that pressure acting on a particular bone tends to increase the thickness of the bone over time and helps better healing of bone fractures. CAUSES OF BONE FRACTURES Individuals with high activity levels appear to be at greater risk for fractures. This group includes children and athletes participating in contact sports. Because of an increase in bone brittleness with aging, elderly persons are also included in this high-risk population. Up to the age of 50, more men suffer from fractures than women due to occupational hazards. However, after the age of 50, women are more prone to fractures than men.
Specific diseases causing an increased risk for fractures include Paget’s disease, rickets, osteogenesis imperfecta, osteoporosis, bone cancer and tumors, and prolonged disuse of a nonfunctional body part such as after a stroke. SYMPTOMS OF BONE FRACTURES Each individual may experience different symptoms depending on the location and impact of fracture. Following are some of the common symptoms of any fracture. •Swelling of the affected area •Inability to carry out functions of the injured area •Deformity of limb •Bruising around the affected area.
Symptoms of fractures usually begin with pain that increases with attempted movement or use of the area and swelling at the involved site. The skin in the area may be pale and an obvious deformity may be present. In more severe cases, there may be a loss of pulse below the fracture site, such as in the extremities, accompanied by numbness, tingling, or paralysis below the fracture. An open or compound fracture is often accompanied by bleeding or bruising. If the lower limbs or pelvis are fractured, pain and resistance to movement usually accompany the injury causing difficulty with weight bearing.
TYPES OF FRACTURES They are broadly classified as Open and Closed fractures: * OPEN (COMPOUND) FRACTURE: An open fracture is a fracture where the broken bone is exposed. That is dangerous because of increased chances of infection. * CLOSED (SIMPLE) FRACTURE : A closed fracture is a fracture where the bone is broken, but the skin is intact. ON THE BASIS OF AETIOLOGY: * TRAUMATIC FRACTURE: A fracture sustained due to trauma is called a traumatic fracture. eg: fractures caused by a fall, road traffic accident etc. * PATHOLOGICAL FRACTURES:
A fracture through a bone which has been made weak by some underlying disease is called a pathological fracture. eg: fracture weakened by a bone by metastasis. ON THE BASIS OF DISPLACEMENTS: Displaced and non-displaced fractures refer to the way the bone breaks. * UNDISPLACED FRACTURE: The bone cracks either part or all of the way through, but does move and maintains its proper alignment. * DISPLACED FRACTURE: The bone snaps into two or more parts and moves so that the two ends are not lined up straight. If the bone is in many pieces, it is called a comminuted fracture.
ON THE BASIS OF PATTERN: * TRANSVERSE FRACTURE: A fracture in which the break is across the bone, at a right angle to the long axis of the bone. * OBLIQUE FRACTURE: Instead of break being at right angle, it goes in oblique direction to the long axis of the bone. The fracture is confined to one plane. In other words the bone has broken at an angle. * SPIRAL FRACTURE: This fracture is easily confused with the oblique fracture. Instead of a straight break as in oblique fracture that is only in one plane, the break in this case traverses both the planes.
* COMMINUTED FRACTURE: This is a fracture with multiple fragments. It is caused by a crushing or compression force along the long axis of the bone. * SEGMENTAL FRACTURE: In this, there are two fractures in one bone, but at different levels. * GREENSTICK OR CRUSH FRACTURE : meaning the bone has not snapped, it’s been stretched or crumpled like soft chalk. Great prognosis and common in kids. Why do fractures hurt so much? Broken bones hurt for a variety of reasons including: * The nerve endings that surround bones contain pain fibre.
These fibres may become irritated when the bone is broken or bruised. * Broken bones bleed, and the blood and associated swelling(edema) causes pain. * Muscles that surround the injured area may go into spasm when they try to hold the broken bone fragments in place, and these spasms may cause further pain. DIAGNOSIS OF FRACTURES * A bone fracture can be diagnosed clinically based on the history given and the physical examination performed. * Imaging by X-ray is often performed to view the bone suspected of being fractured.
* In situations where x-ray alone is insufficient, a computed tomography (CT scan) or MRI (magnetic resonance imaging) may be performed. TREATMENT OF BONE FRACTURES X-rays are often used to located assess fractures. The broken pieces may need to be put back in place and then immobilized until the bones can heal as new bone forms around the break. BONE HEALING Immediately after a bone fracture the body forms a protective blood clot and callus or fibrous tissue to protect the injured area. New bone cells start forming at the edges of fracture site and grow toward each other.
Over time the fracture closes completely and the bony callus is absorbed. TREATMENT FOR FRACTURES The type of treatment will depend on the kind of fracture and the specific bones involved. •Casting — After the broken bones have been manipulated back into their proper positions, a plaster or fiberglass cast is applied to keep the bones from moving while they heal. •External fixation — Pins or wires are set into the bone through the skin above and below the fracture. These are connected to a ring or a bar outside the skin that holds the pins in place.
After the bones have healed, the pins are removed. •Internal fixation — In a surgical procedure, metal rods, wires, or screws are inserted in the bone fragments to keep them together. PHYSICAL THERAPY After the bone has healed it may be necessary to restore muscle strength as well as mobility to the affected area. If the fracture occurred near or through a joint there is a risk of permanent stiffness – the individual may not be able to bend that joint as well as before. SURGERY If there was damage to the skin and soft tissue around the affected bone or joint, plastic surgery may be required.
Delayed unions and non-unions: Non-unions are fractures that fail to heal, while delayed unions are those that take longer to heal. * Ultrasound therapy – low-intensity ultrasound is applied daily to the affected area. This has been found to help the fracture to heal. Studies in this area are still ongoing. * Bone graft – if the fracture does not heal a natural or synthetic bone is transplanted to stimulate the broken bone. * Stem cell therapy – studies are currently underway to see whether stem cells can be used to heal fractures that do not heal. PAIN MANAGEMENT
In arm fractures in children, ibuprofen has been found to be equally effective as the combination of acetaminophen and codeine. COMPLICATIONS OF FRACTURE It could either be early or delayed. The early complications of fracture are the following: 1. Shock 2. Fat embolism 3. Compartment syndrome 4. Infection 5. Disseminated intravascular coagulation (DIC) PREVENTION OF FRACTURES NUTRITION AND SUNLIGHT The human body needs adequate supplies of calcium for healthy bones. Milk, cheese, yoghurt and dark green leafy vegetables are good sources of calcium.
Our body needs vitamin D to absorb calcium – exposure to sunlight, as well as eating eggs and oily fish are good ways of getting vitamin D. PHYSICAL ACTIVITY The more weight-bearing exercises you do, the stronger and denser your bones will be. Examples include skipping, walking, running, and dancing – any exercise where the body pulls on the skeleton. Older age not only results in weaker bones, but often in less physical activity, which further increases the risk of even weaker bones. It is important for people of all ages to stay physically active. THE (FEMALE) MENOPAUSE
Estrogen, which regulates a woman’s calcium, starts to drop and continues to do so until after the menopause; levels never come back up to pre-menopausal levels. In other words, calcium regulation is much more difficult after the menopause. Consequently, women need to be especially careful about the density and strength of their bones during and after the menopause. The following steps may help reduce post-menopausal osteoporosis risk: •Do several short weight-bearing exercise sessions each week. •Do not smoke. •Consume only moderate quantities of alcohol, or don’t drink it.
•Make sure you get adequate exposure to daylight. •Make sure your diet has plenty of calcium-rich foods. For those who find this difficult, talk to your doctor about taking calcium supplements. FIRST AID * Try to maintain the patient still and composed. Prevent unnecessary movement arising out of anxiety or fear. * Examine the person closely for the presence of other injuries and call for medical help. If medical help is quickly available, handover the patient to them for further treatment. * If there is a break in the skin surface, it can be rinsed to remove any visible dirt or other potential contamination.
However, vigorous flushing or scrubbing of the wound should be avoided. * The broken bones can be immobilised with either a splint or string. Rolls of newspaper or strips of wood can be used. It is important to immobilize the area both above and below the injured bone. * 5. Ice packs can be applied to reduce pain and swelling (Not to be placed directly over the wound. * NOTE: DO NOT move the person if a head, neck, or back injury is suspected as this can worsen the injury, leading to life threatening complications.